Basic Information
| Provider Information | |||||||||
| NPI: | 1184810319 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FUNCTIONAL RESTORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 491149 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900499149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187086163 | ||||||||
| FaxNumber: | 8187086167 | ||||||||
| Practice Location | |||||||||
| Address1: | 18065 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913163517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187086163 | ||||||||
| FaxNumber: | 8187086167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2007 | ||||||||
| LastUpdateDate: | 10/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | HEIKALI | ||||||||
| AuthorizedOfficialFirstName: | MOOSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8187086163 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0015X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychosomatic Medicine | 2084P2900X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Pain Medicine |
No ID Information.