Provider Demographics
NPI:1003847435
Name:SOUTHERN CALIFORNIA HEAD PAIN AND NEUROLOGIC INSTITUTE INC
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA HEAD PAIN AND NEUROLOGIC INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-648-3158
Mailing Address - Street 1:3555 LOMA VISTA RD
Mailing Address - Street 2:STE 115
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3161
Mailing Address - Country:US
Mailing Address - Phone:805-648-3158
Mailing Address - Fax:805-648-2997
Practice Address - Street 1:3555 LOMA VISTA RD
Practice Address - Street 2:#115
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3161
Practice Address - Country:US
Practice Address - Phone:805-648-3158
Practice Address - Fax:805-648-2997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA608782084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA60878OtherLICENSE
CAW19218OtherMEDICARE PTAN
CAW19218OtherMEDICARE PTAN
CAH37334Medicare UPIN