Healthcare Provider Details

I. General information

NPI: 1689844672
Provider Name (Legal Business Name): ROY D NINI MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 N HARBOR BLVD SUITE #100
FULLERTON CA
92835-4127
US

IV. Provider business mailing address

122 SHELDON ST
EL SEGUNDO CA
90245-3915
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-9885
  • Fax: 310-423-9819
Mailing address:
  • Phone: 310-322-4278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA79898
License Number StateCA

VIII. Authorized Official

Name: ROY D NINI
Title or Position: PRESIDENT
Credential: MD
Phone: 714-441-4700