Provider Demographics
NPI:1396846762
Name:FUNCTIONAL RESTORATION MEDICAL CENTER, INC,
Entity Type:Organization
Organization Name:FUNCTIONAL RESTORATION MEDICAL CENTER, INC,
Other - Org Name:IRVINE OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOOSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIKALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-432-1000
Mailing Address - Street 1:9134 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3540
Mailing Address - Country:US
Mailing Address - Phone:310-432-1000
Mailing Address - Fax:310-432-4321
Practice Address - Street 1:15825 LAGUNA CANYON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2125
Practice Address - Country:US
Practice Address - Phone:949-777-9000
Practice Address - Fax:949-777-9007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13197Medicare ID - Type Unspecified