Healthcare Provider Details

I. General information

NPI: 1184938623
Provider Name (Legal Business Name): PAUL H ACKERMAN M D INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11980 SAN VICENTE BLVD SUITE 621
LOS ANGELES CA
90049-5012
US

IV. Provider business mailing address

11980 SAN VICENTE BLVD SUITE 621
LOS ANGELES CA
90049-5012
US

V. Phone/Fax

Practice location:
  • Phone: 310-826-4882
  • Fax: 310-476-5819
Mailing address:
  • Phone: 310-826-4882
  • Fax: 310-476-5819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberG11839
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberG11839
License Number StateCA

VIII. Authorized Official

Name: DR. PAUL H ACKERMAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-826-4882