Healthcare Provider Details

I. General information

NPI: 1790556348
Provider Name (Legal Business Name): AGILE OCCUPATIONAL MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 01/12/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16055 VENTURA BLVD STE 120
ENCINO CA
91436-2635
US

IV. Provider business mailing address

3200 BRISTOL ST STE 600
COSTA MESA CA
92626-1810
US

V. Phone/Fax

Practice location:
  • Phone: 818-386-5575
  • Fax: 818-514-2024
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PETER MURRAY
Title or Position: VP, STRATEGY AND INNOVATION
Credential:
Phone: 571-224-5886