Basic Information
| Provider Information | |||||||||
| NPI: | 1720378300 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENCINO MEDICAL URGENT CARE INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18055 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913163517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188818117 | ||||||||
| FaxNumber: | 8189968972 | ||||||||
| Practice Location | |||||||||
| Address1: | 18055 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913163517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188818117 | ||||||||
| FaxNumber: | 8189968972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2011 | ||||||||
| LastUpdateDate: | 04/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | HEDVAT | ||||||||
| AuthorizedOfficialFirstName: | YAHYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8188818117 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1306830021 | 05 | CA | MEDICAID |