Healthcare Provider Details

I. General information

NPI: 1790204139
Provider Name (Legal Business Name): ACT-LINE MEDICAL, INC., A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16311 VENTURA BLVD STE 106
ENCINO CA
91436-2124
US

IV. Provider business mailing address

16311 VENTURA BLVD STE 106
ENCINO CA
91436-2124
US

V. Phone/Fax

Practice location:
  • Phone: 310-278-7000
  • Fax: 310-321-4510
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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