Provider Demographics
NPI:1528226073
Name:LANKERSHIM MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:LANKERSHIM MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPIETOR
Authorized Official - Prefix:
Authorized Official - First Name:BEHROUZ
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOMAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-761-2300
Mailing Address - Street 1:6056 LANKERSHIM BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-4806
Mailing Address - Country:US
Mailing Address - Phone:818-761-2300
Mailing Address - Fax:818-761-5066
Practice Address - Street 1:6056 LANKERSHIM BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-4806
Practice Address - Country:US
Practice Address - Phone:818-761-2300
Practice Address - Fax:818-761-5066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA043704208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A437040Medicaid