Provider Demographics
NPI:1497944557
Name:ABM MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:ABM MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTEZAIEFARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:818-222-8042
Mailing Address - Street 1:22554 VENTURA BLVD STE 201
Mailing Address - Street 2:STE 201
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-1480
Mailing Address - Country:US
Mailing Address - Phone:818-222-8042
Mailing Address - Fax:818-222-2240
Practice Address - Street 1:22554 VENTURA BLVD STE 201
Practice Address - Street 2:STE 201
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91364-1480
Practice Address - Country:US
Practice Address - Phone:818-222-8042
Practice Address - Fax:818-222-2240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7100261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16713Medicare PIN