Healthcare Provider Details

I. General information

NPI: 1053550293
Provider Name (Legal Business Name): ENCINO SPORTS MEDICINE GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16500 VENTURA BLVD 360
ENCINO CA
91436-2011
US

IV. Provider business mailing address

16500 VENTURA BLVD 360
ENCINO CA
91436-2011
US

V. Phone/Fax

Practice location:
  • Phone: 818-986-1210
  • Fax: 818-986-1029
Mailing address:
  • Phone: 818-986-1210
  • Fax: 818-986-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG7818
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberG29768
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC28811
License Number StateCA

VIII. Authorized Official

Name: STEVEN KAYE
Title or Position: CEO
Credential: MD
Phone: 818-986-1210