Provider Demographics
NPI:1851446132
Name:THE ADOLESCENT AND CHILDREN'S ORTHOPEDIC SURGEONS
Entity Type:Organization
Organization Name:THE ADOLESCENT AND CHILDREN'S ORTHOPEDIC SURGEONS
Other - Org Name:FAMILY ORTHOPEDIC AND REHABILITATION CENTER ENCINO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BROOKENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-789-9449
Mailing Address - Street 1:5353 BALBOA BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2804
Mailing Address - Country:US
Mailing Address - Phone:818-789-9449
Mailing Address - Fax:818-789-9339
Practice Address - Street 1:5353 BALBOA BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2804
Practice Address - Country:US
Practice Address - Phone:818-789-9449
Practice Address - Fax:818-789-9339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79821207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H70096Medicare UPIN