Healthcare Provider Details

I. General information

NPI: 1427035617
Provider Name (Legal Business Name): CARDIOVASCULAR CONSULTANTS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 08/23/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16542 VENTURA BLVD STE 402
ENCINO CA
91436-4562
US

IV. Provider business mailing address

16542 VENTURA BLVD STE 402
ENCINO CA
91436-4562
US

V. Phone/Fax

Practice location:
  • Phone: 818-782-5041
  • Fax: 818-205-9091
Mailing address:
  • Phone: 818-782-5041
  • Fax: 818-205-9091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberFNP7299
License Number StateCA

VIII. Authorized Official

Name: KIMBERLEY A LITKE
Title or Position: ASST ADMINISTRATOR
Credential:
Phone: 818-782-5041