Healthcare Provider Details

I. General information

NPI: 1538331848
Provider Name (Legal Business Name): GREGG SMALL MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15720 VENTURA BLVD SUITE 227
ENCINO CA
91436-2914
US

IV. Provider business mailing address

15720 VENTURA BLVD SUITE 227
ENCINO CA
91436-2914
US

V. Phone/Fax

Practice location:
  • Phone: 818-907-7828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberG70119
License Number StateCA

VIII. Authorized Official

Name: GREGG SMALL
Title or Position: OWNER
Credential: M.D.
Phone: 818-907-7828