Provider Demographics
NPI:1477746907
Name:ROSSCOE VAN NUYS MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:ROSSCOE VAN NUYS MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OVNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWATMEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-782-1982
Mailing Address - Street 1:8121 VAN NUYS BLVD STE 414
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-5120
Mailing Address - Country:US
Mailing Address - Phone:818-782-1982
Mailing Address - Fax:818-782-1935
Practice Address - Street 1:8121 VAN NUYS BLVD STE 414
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-5120
Practice Address - Country:US
Practice Address - Phone:818-782-1982
Practice Address - Fax:818-782-1935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC20620111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18601Medicare PIN