Healthcare Provider Details

I. General information

NPI: 1942699236
Provider Name (Legal Business Name): MAJOR MEDICAL MANAGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 S CENTRAL AVE STE 120
GLENDALE CA
91204-2500
US

IV. Provider business mailing address

14624 SHERMAN WAY STE 306
VAN NUYS CA
91405-2241
US

V. Phone/Fax

Practice location:
  • Phone: 818-242-3668
  • Fax:
Mailing address:
  • Phone: 818-242-3668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberE3817
License Number StateCA

VIII. Authorized Official

Name: DR. CHARLES BLAINE
Title or Position: PODIATRIC SURGEON
Credential: DPM
Phone: 818-242-3668