Provider Demographics
NPI:1821498635
Name:BRENTWOOD ORTHOPEDIC AND SPINE SURGERY LLC
Entity Type:Organization
Organization Name:BRENTWOOD ORTHOPEDIC AND SPINE SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOSHE
Authorized Official - Middle Name:H
Authorized Official - Last Name:WILKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-337-7463
Mailing Address - Street 1:11980 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5012
Mailing Address - Country:US
Mailing Address - Phone:310-337-7463
Mailing Address - Fax:310-442-8336
Practice Address - Street 1:11980 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5012
Practice Address - Country:US
Practice Address - Phone:310-337-7463
Practice Address - Fax:310-442-8336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-28
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100370261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical