Provider Demographics
NPI:1417189341
Name:HEALTHY HEARTS MEDICAL GROUP INC
Entity Type:Organization
Organization Name:HEALTHY HEARTS MEDICAL GROUP INC
Other - Org Name:CLINICA LATINO AMERICANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARYSOUH
Authorized Official - Middle Name:Y
Authorized Official - Last Name:KASHANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-899-5555
Mailing Address - Street 1:8727 VAN NUYS BLVD
Mailing Address - Street 2:103
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-2451
Mailing Address - Country:US
Mailing Address - Phone:818-899-5555
Mailing Address - Fax:818-899-5969
Practice Address - Street 1:8727 VAN NUYS BLVD
Practice Address - Street 2:101
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-2451
Practice Address - Country:US
Practice Address - Phone:818-892-6414
Practice Address - Fax:818-899-5969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-11
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG80771Medicare UPIN