Provider Demographics
NPI:1700884871
Name:ENCINO NEUROLOGICAL MEDICAL GROUP
Entity Type:Organization
Organization Name:ENCINO NEUROLOGICAL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FREUNDLICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-990-8561
Mailing Address - Street 1:16311 VENTURA BLVD
Mailing Address - Street 2:SUITE 680
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2124
Mailing Address - Country:US
Mailing Address - Phone:818-990-8561
Mailing Address - Fax:818-990-4432
Practice Address - Street 1:16311 VENTURA BLVD
Practice Address - Street 2:SUITE 680
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2124
Practice Address - Country:US
Practice Address - Phone:818-990-8561
Practice Address - Fax:818-990-4432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG021066174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW3924Medicare ID - Type Unspecified