MEDICARE: FUNDAMENTAL HEALTH CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center	G080589	CA

General Provider Information

NPI Number	:	1023475431
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNDAMENTAL HEALTH CENTER LLC

Provider Business Mailing Address
First Line	:	10323 SANTA MONICA BLVD
Second Line	:	#109
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-6071
Country	:	US
Telephone Number	:	213-364-2906
Fax Number	:

Provider Business Practice Location Address
First Line	:	10323 SANTA MONICA BLVD
Second Line	:	#109
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-6071
Country	:	US
Telephone Number	:	213-364-2906
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. DARREN CHRISTOPHER MISARESH
Credential	:	MBA
Telephone Number	:	213-364-2906

Provider Enumeration Date	:	01/15/2016
Last Update Date	:	01/15/2016

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