Healthcare Provider Details

I. General information

NPI: 1578082038
Provider Name (Legal Business Name): OUT-LINE MEDICAL, INC., A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16311 VENTURA BLVD STE 1065
ENCINO CA
91436-4349
US

IV. Provider business mailing address

16311 VENTURA BLVD STE 1065
ENCINO CA
91436-4349
US

V. Phone/Fax

Practice location:
  • Phone: 424-217-1292
  • Fax: 424-217-1293
Mailing address:
  • Phone: 424-217-1292
  • Fax: 424-217-1293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number75506
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number14719
License Number StateCA

VIII. Authorized Official

Name: DR. TOORAJ GRAVORI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-755-8333