Provider Demographics
NPI:1942699236
Name:MAJOR MEDICAL MANAGEMENT, INC.
Entity Type:Organization
Organization Name:MAJOR MEDICAL MANAGEMENT, INC.
Other - Org Name:VALLEY REGIONAL SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PODIATRIC SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAINE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-242-3668
Mailing Address - Street 1:14624 SHERMAN WAY
Mailing Address - Street 2:STE 306
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2241
Mailing Address - Country:US
Mailing Address - Phone:818-242-3668
Mailing Address - Fax:
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:STE 120
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2500
Practice Address - Country:US
Practice Address - Phone:818-242-3668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3817261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical