Provider Demographics
NPI:1790204139
Name:ACT-LINE MEDICAL, INC., A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ACT-LINE MEDICAL, INC., A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TOORAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVORI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-755-8333
Mailing Address - Street 1:16311 VENTURA BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16311 VENTURA BLVD STE 106
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:310-278-7000
Practice Address - Fax:310-321-4510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-18
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75506207T00000X
CA14719208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty