Healthcare Provider Details

I. General information

NPI: 1912443490
Provider Name (Legal Business Name): GENESIS FUNCTIONAL RESTORATION CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 S BUENA VISTA ST 335
BURBANK CA
91505-4554
US

IV. Provider business mailing address

191 S BUENA VISTA ST 335
BURBANK CA
91505-4554
US

V. Phone/Fax

Practice location:
  • Phone: 323-697-2330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KAMRON KENNETH HAKHAMIMI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 323-697-2330