Healthcare Provider Details

I. General information

NPI: 1427509033
Provider Name (Legal Business Name): INTERVENTIONAL SPINE CARE & ORTHOPEDIC REGENERATIVE EXPERTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S CENTRAL AVE STE 301
GLENDALE CA
91204-4388
US

IV. Provider business mailing address

PO BOX 8232
LA CRESCENTA CA
91224-0232
US

V. Phone/Fax

Practice location:
  • Phone: 818-338-6860
  • Fax: 888-425-9079
Mailing address:
  • Phone: 818-913-9356
  • Fax: 818-369-7177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number118692
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA118692
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number118692
License Number StateCA

VIII. Authorized Official

Name: DR. MAXIM MORADIAN
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 818-913-9356