Provider Demographics
NPI:1609118983
Name:SALAM F ALKASSPOOLES M D AMC
Entity Type:Organization
Organization Name:SALAM F ALKASSPOOLES M D AMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SALAM
Authorized Official - Middle Name:F
Authorized Official - Last Name:ALKASSPOOLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-652-0092
Mailing Address - Street 1:11633 SAN VICENTE BLVD STE 314
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-6514
Mailing Address - Country:US
Mailing Address - Phone:310-207-0020
Mailing Address - Fax:310-207-0030
Practice Address - Street 1:11633 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 314
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6511
Practice Address - Country:US
Practice Address - Phone:310-207-0020
Practice Address - Fax:310-207-0030
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SALAM F ALKASSPOOLES M D AMC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-25
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00818020Medicaid
CAHB455AMedicare PIN
CA00818020Medicaid