Provider Demographics
NPI:1467511592
Name:HEALTHY HEART MEDICAL GROUP INC
Entity Type:Organization
Organization Name:HEALTHY HEART MEDICAL GROUP INC
Other - Org Name:PACOIMA PRIMARY CARE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARYOUSH
Authorized Official - Middle Name:YALLYA
Authorized Official - Last Name:KASHANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-899-5555
Mailing Address - Street 1:18653 VENTURA BLVD
Mailing Address - Street 2:289
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356
Mailing Address - Country:US
Mailing Address - Phone:818-899-5555
Mailing Address - Fax:818-899-5969
Practice Address - Street 1:12502 VAN NUYS BLVD
Practice Address - Street 2:104
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331
Practice Address - Country:US
Practice Address - Phone:818-899-5555
Practice Address - Fax:818-899-5969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A666980Medicaid
G80771Medicare UPIN
CAW14952Medicare ID - Type Unspecified