Provider Demographics
NPI:1356558209
Name:PHYSICAL MEDICINE INSTITUTE
Entity type:Organization
Organization Name:PHYSICAL MEDICINE INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASST
Authorized Official - Prefix:MS
Authorized Official - First Name:LILIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:818-905-3355
Mailing Address - Street 1:11693 SAN VICENTE BLVD # 523
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5105
Mailing Address - Country:US
Mailing Address - Phone:818-905-3355
Mailing Address - Fax:818-905-0044
Practice Address - Street 1:14925 BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91411-3610
Practice Address - Country:US
Practice Address - Phone:818-905-3355
Practice Address - Fax:818-905-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61974174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A61974Medicaid
CA1710955539OtherINDIVIDUAL NPI
CA1710955539OtherINDIVIDUAL NPI
CAA61974Medicare ID - Type Unspecified
CA00A61974Medicaid