Provider Demographics
NPI:1740236728
Name:ORTHOPEDIC PAIN MANAGEMENT CENTER, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ORTHOPEDIC PAIN MANAGEMENT CENTER, A MEDICAL CORPORATION
Other - Org Name:JOINT SPINE & SPORT ORTHOPEDIC PAIN MANAGEMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD ALI
Authorized Official - Middle Name:
Authorized Official - Last Name:DORAFSHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-999-0099
Mailing Address - Street 1:16952 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-4197
Mailing Address - Country:US
Mailing Address - Phone:818-789-3964
Mailing Address - Fax:818-789-3967
Practice Address - Street 1:16952 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-4197
Practice Address - Country:US
Practice Address - Phone:818-789-3964
Practice Address - Fax:818-789-3967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5157130001Medicare NSC
CAW16994Medicare PIN