Healthcare Provider Details

I. General information

NPI: 1770774366
Provider Name (Legal Business Name): SUPERIOR MULTI SPECIALTY MEDICAL CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 02/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 VENICE BLVD
LOS ANGELES CA
90066-4014
US

IV. Provider business mailing address

11600 VENICE BLVD
LOS ANGELES CA
90066-4014
US

V. Phone/Fax

Practice location:
  • Phone: 310-390-9551
  • Fax: 310-390-9296
Mailing address:
  • Phone: 310-390-9551
  • Fax: 310-390-9296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License NumberA50372
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberA50372
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA50372
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberA50372
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberA50312
License Number StateCA

VIII. Authorized Official

Name: REZA RAY EHSAN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-390-9551