Provider Demographics
NPI:1588803241
Name:HERITAGE ORTHOPEDIC & INDUSTRIAL MEDICINE MULTI-SPECIALTY MED GRP, INC
Entity Type:Organization
Organization Name:HERITAGE ORTHOPEDIC & INDUSTRIAL MEDICINE MULTI-SPECIALTY MED GRP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-716-9434
Mailing Address - Street 1:22030 SHERMAN WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-1844
Mailing Address - Country:US
Mailing Address - Phone:818-716-9434
Mailing Address - Fax:
Practice Address - Street 1:22030 SHERMAN WAY STE 101
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91303-1844
Practice Address - Country:US
Practice Address - Phone:818-716-9434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62809111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty