Healthcare Provider Details

I. General information

NPI: 1336726249
Provider Name (Legal Business Name): JASON REN NI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 WESTWOOD PLZ
LOS ANGELES CA
90095-8358
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-9111
  • Fax:
Mailing address:
  • Phone: 310-301-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA192611
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA192611
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: