Healthcare Provider Details

I. General information

NPI: 1306365523
Provider Name (Legal Business Name): FREDERIC MASSOUA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 S VERMONT AVE
LOS ANGELES CA
90044-3423
US

IV. Provider business mailing address

8401 S VERMONT AVE
LOS ANGELES CA
90044-3423
US

V. Phone/Fax

Practice location:
  • Phone: 424-221-0662
  • Fax:
Mailing address:
  • Phone: 424-221-0662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95451598
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: