Healthcare Provider Details

I. General information

NPI: 1538309141
Provider Name (Legal Business Name): HERITAGE ORTHOPEDIC & INDUSTRIAL MEDICINE MULTI-SPECIALTY GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 02/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 SANTA ANITA AVE STE 114
EL MONTE CA
91733-1369
US

IV. Provider business mailing address

17750 SHERMAN WAY STE 100
RESEDA CA
91335-8331
US

V. Phone/Fax

Practice location:
  • Phone: 626-350-3990
  • Fax:
Mailing address:
  • Phone: 818-705-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License NumberA85704
License Number StateCA

VIII. Authorized Official

Name: DR. ALLEN FONSECA
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 818-705-7200