Provider Demographics
NPI:1235433657
Name:ENCINO NEURODIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:ENCINO NEURODIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOOSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIKALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-708-6163
Mailing Address - Street 1:PO BOX 49911
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-0911
Mailing Address - Country:US
Mailing Address - Phone:818-708-6163
Mailing Address - Fax:818-708-6167
Practice Address - Street 1:16661 VENTURA BLVD
Practice Address - Street 2:226
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-1914
Practice Address - Country:US
Practice Address - Phone:818-708-6163
Practice Address - Fax:818-708-6167
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:F&M RADIOLOGY MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40559204C00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty