Healthcare Provider Details

I. General information

NPI: 1487987848
Provider Name (Legal Business Name): MR. ZACK MAXWELL GEORGE OLDENBURG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD # 115
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

1751 WINONA BLVD APT 4
LOS ANGELES CA
90027-3824
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-6675
  • Fax:
Mailing address:
  • Phone: 310-422-7996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: