Provider Demographics
NPI:1467829291
Name:COMPREHENSIVE MATERNAL-FETAL MEDICINE CENTER, A PROFESSIONAL MED CORP
Entity Type:Organization
Organization Name:COMPREHENSIVE MATERNAL-FETAL MEDICINE CENTER, A PROFESSIONAL MED CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:ZION
Authorized Official - Last Name:MANSANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-345-2455
Mailing Address - Street 1:5343 OSTROM AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2631
Mailing Address - Country:US
Mailing Address - Phone:818-345-2455
Mailing Address - Fax:818-344-3101
Practice Address - Street 1:18399 VENTURA BLVD
Practice Address - Street 2:249
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4233
Practice Address - Country:US
Practice Address - Phone:818-345-2455
Practice Address - Fax:818-344-3101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA84716174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty