Basic Information
| Provider Information | |||||||||
| NPI: | 1891042123 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | F&M RADIOLOGY MEDICAL CENTER INC | ||||||||
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| OtherOrganizationName: | UNITED SLEEP LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18065 VENTURA BLVD | ||||||||
| Address2: | ENCINO | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913163517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187086163 | ||||||||
| FaxNumber: | 8183441390 | ||||||||
| Practice Location | |||||||||
| Address1: | 16661 VENTURA BLVD | ||||||||
| Address2: | 226 | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914361914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188495903 | ||||||||
| FaxNumber: | 8187761069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2012 | ||||||||
| LastUpdateDate: | 08/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | HEIKALI | ||||||||
| AuthorizedOfficialFirstName: | MOOSSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/MEDICAL DIRECTOR/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8187086163 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | F&M RADIOLOGY MEDICAL CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 2084S0012X | A40559 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Sleep Medicine |
No ID Information.