Healthcare Provider Details

I. General information

NPI: 1184810319
Provider Name (Legal Business Name): FUNCTIONAL RESTORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2007
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18065 VENTURA BLVD
ENCINO CA
91316-3517
US

IV. Provider business mailing address

PO BOX 491149
LOS ANGELES CA
90049-9149
US

V. Phone/Fax

Practice location:
  • Phone: 818-708-6163
  • Fax: 818-708-6167
Mailing address:
  • Phone: 818-708-6163
  • Fax: 818-708-6167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MOOSA HEIKALI
Title or Position: PRESIDENT/MEDICAL DIRECTOR
Credential: M.D.
Phone: 818-708-6163