Healthcare Provider Details

I. General information

NPI: 1184370199
Provider Name (Legal Business Name): ACTIVE MOBILE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 WILSHIRE BLVD STE 1200
LOS ANGELES CA
90010-2214
US

IV. Provider business mailing address

3325 WILSHIRE BLVD STE 208
LOS ANGELES CA
90010-1733
US

V. Phone/Fax

Practice location:
  • Phone: 213-465-2643
  • Fax: 213-232-4944
Mailing address:
  • Phone: 213-465-2643
  • Fax: 213-232-4944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOANNA BALASICO
Title or Position: VICE PRESIDENT
Credential: RN
Phone: 213-465-2643