Provider Demographics
NPI:1043642358
Name:PORTER RANCH INTEGRATIVE MEDICAL CLINIC, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PORTER RANCH INTEGRATIVE MEDICAL CLINIC, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:
Authorized Official - Last Name:ANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:818-831-8000
Mailing Address - Street 1:11177 TAMPA AVE
Mailing Address - Street 2:STE A
Mailing Address - City:PORTER RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91326-2254
Mailing Address - Country:US
Mailing Address - Phone:818-831-8000
Mailing Address - Fax:818-831-8005
Practice Address - Street 1:11177 TAMPA AVE
Practice Address - Street 2:STE A
Practice Address - City:PORTER RANCH
Practice Address - State:CA
Practice Address - Zip Code:91326-2254
Practice Address - Country:US
Practice Address - Phone:818-831-8000
Practice Address - Fax:818-831-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty