Provider Demographics
NPI:1861629222
Name:RESEDA FAMILY MEDICINE CLINIC AND MULTI-SPECIALTY GROUP
Entity Type:Organization
Organization Name:RESEDA FAMILY MEDICINE CLINIC AND MULTI-SPECIALTY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SYRUS
Authorized Official - Middle Name:
Authorized Official - Last Name:FERIDOUNI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-744-4369
Mailing Address - Street 1:6830 RESEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335
Mailing Address - Country:US
Mailing Address - Phone:818-996-4888
Mailing Address - Fax:818-996-5888
Practice Address - Street 1:6830 RESEDA BLVD
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335
Practice Address - Country:US
Practice Address - Phone:818-996-4888
Practice Address - Fax:818-996-5888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-12
Last Update Date:2009-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000242910900017261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center