Healthcare Provider Details

I. General information

NPI: 1588803241
Provider Name (Legal Business Name): HERITAGE ORTHOPEDIC & INDUSTRIAL MEDICINE MULTI-SPECIALTY MED GRP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22030 SHERMAN WAY STE 101
CANOGA PARK CA
91303-1844
US

IV. Provider business mailing address

22030 SHERMAN WAY STE 101
CANOGA PARK CA
91303-1844
US

V. Phone/Fax

Practice location:
  • Phone: 818-716-9434
  • Fax:
Mailing address:
  • Phone: 818-716-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberG62809
License Number StateCA

VIII. Authorized Official

Name: DR. ALLEN FONSECA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 818-716-9434