Healthcare Provider Details

I. General information

NPI: 1003415993
Provider Name (Legal Business Name): SRLA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16830 VENTURA BLVD STE 150
ENCINO CA
91436-1722
US

IV. Provider business mailing address

16830 VENTURA BLVD STE 150
ENCINO CA
91436-1722
US

V. Phone/Fax

Practice location:
  • Phone: 818-986-1203
  • Fax: 818-986-1282
Mailing address:
  • Phone: 818-986-1203
  • Fax: 818-986-1282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SARGIS KHAZIRAN
Title or Position: MANAGER
Credential:
Phone: 818-986-1203