Healthcare Provider Details

I. General information

NPI: 1679945695
Provider Name (Legal Business Name): SOCAL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2015
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8207 MULHOLLAND DR
LOS ANGELES CA
90046-1132
US

IV. Provider business mailing address

6053 BRISTOL PKWY
CULVER CITY CA
90230-6601
US

V. Phone/Fax

Practice location:
  • Phone: 800-724-8207
  • Fax: 800-729-8207
Mailing address:
  • Phone: 323-364-6489
  • Fax: 800-729-8207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number35886
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number136475
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number66975
License Number StateCA

VIII. Authorized Official

Name: TERRY SCHOSER
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 323-364-6489