Basic Information
| Provider Information | |||||||||
| NPI: | 1235433657 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENCINO NEURODIAGNOSTIC CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 49911 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900490911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187086163 | ||||||||
| FaxNumber: | 8187086167 | ||||||||
| Practice Location | |||||||||
| Address1: | 16661 VENTURA BLVD | ||||||||
| Address2: | 226 | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914361914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187086163 | ||||||||
| FaxNumber: | 8187086167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2010 | ||||||||
| LastUpdateDate: | 12/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | HEIKALI | ||||||||
| AuthorizedOfficialFirstName: | MOOSSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8187086163 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | F&M RADIOLOGY MEDICAL CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204C00000X | A40559 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine, Sports Medicine | 2084N0400X | A40559 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.