Healthcare Provider Details

I. General information

NPI: 1174152003
Provider Name (Legal Business Name): VADIM GELLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4549 WHITE OAK PL
ENCINO CA
91316-4334
US

IV. Provider business mailing address

4549 WHITE OAK PL
ENCINO CA
91316-4334
US

V. Phone/Fax

Practice location:
  • Phone: 310-936-7523
  • Fax:
Mailing address:
  • Phone: 310-936-7523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: