Provider Demographics
NPI:1023475431
Name:FUNDAMENTAL HEALTH CENTER LLC
Entity type:Organization
Organization Name:FUNDAMENTAL HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:MISARESH
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:213-364-2906
Mailing Address - Street 1:10323 SANTA MONICA BLVD
Mailing Address - Street 2:#109
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6071
Mailing Address - Country:US
Mailing Address - Phone:213-364-2906
Mailing Address - Fax:
Practice Address - Street 1:10323 SANTA MONICA BLVD
Practice Address - Street 2:#109
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6071
Practice Address - Country:US
Practice Address - Phone:213-364-2906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG080589261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health