Healthcare Provider Details

I. General information

NPI: 1841977253
Provider Name (Legal Business Name): PRIMARY CARE SPORTS MEDICINE A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29229 CANWOOD ST STE 112
AGOURA HILLS CA
91301-1561
US

IV. Provider business mailing address

18411 CLARK ST STE 302
TARZANA CA
91356-3541
US

V. Phone/Fax

Practice location:
  • Phone: 818-501-7276
  • Fax: 818-501-7288
Mailing address:
  • Phone: 818-501-7276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: BYRON PATTERSON
Title or Position: CEO
Credential:
Phone: 818-501-7276