Provider Demographics
NPI:1912928037
Name:SAN FERNANDO VALLEY PULMONARY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:SAN FERNANDO VALLEY PULMONARY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JENKINS
Authorized Official - Last Name:ENCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-609-7536
Mailing Address - Street 1:18399 VENTURA BLVD
Mailing Address - Street 2:SUITE 245
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4233
Mailing Address - Country:US
Mailing Address - Phone:818-609-7536
Mailing Address - Fax:818-344-9670
Practice Address - Street 1:18399 VENTURA BLVD
Practice Address - Street 2:SUITE 245
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4233
Practice Address - Country:US
Practice Address - Phone:818-609-7536
Practice Address - Fax:818-344-9670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0001370Medicaid
CAGR0001370Medicaid