Healthcare Provider Details

I. General information

NPI: 1235433657
Provider Name (Legal Business Name): ENCINO NEURODIAGNOSTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16661 VENTURA BLVD 226
ENCINO CA
91436-1914
US

IV. Provider business mailing address

PO BOX 49911
LOS ANGELES CA
90049-0911
US

V. Phone/Fax

Practice location:
  • Phone: 818-708-6163
  • Fax: 818-708-6167
Mailing address:
  • Phone: 818-708-6163
  • Fax: 818-708-6167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberA40559
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA40559
License Number StateCA

VIII. Authorized Official

Name: DR. MOOSSA HEIKALI
Title or Position: OWNER/MEDICAL DIRECTOR
Credential: M.D
Phone: 818-708-6163