Basic Information
| Provider Information | |||||||||
| NPI: | 1285735621 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FUNCTIONAL RESTORATION MEDICAL CENTER, INC, | ||||||||
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| OtherOrganizationName: | SINA IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9134 W OLYMPIC BLVD | ||||||||
| Address2: | |||||||||
| City: | BEVERLY HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902123540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104321000 | ||||||||
| FaxNumber: | 3104324321 | ||||||||
| Practice Location | |||||||||
| Address1: | 16161 GOTHARD ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | HUNTINGTON BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926473603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148436255 | ||||||||
| FaxNumber: | 7148426957 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HEIKALI | ||||||||
| AuthorizedOfficialFirstName: | MOOSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3104321000 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.