Healthcare Provider Details

I. General information

NPI: 1437568235
Provider Name (Legal Business Name): JE MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9461 CHARLEVILLE BLVD # 242
BEVERLY HILLS CA
90212-3017
US

IV. Provider business mailing address

9461 CHARLEVILLE BLVD # 242
BEVERLY HILLS CA
90212-3017
US

V. Phone/Fax

Practice location:
  • Phone: 310-292-4883
  • Fax: 310-861-1711
Mailing address:
  • Phone: 310-292-4883
  • Fax: 310-861-1711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberA73998
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA73998
License Number StateCA

VIII. Authorized Official

Name: ALI JOHN ENAYATI
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 310-292-4883