Healthcare Provider Details

I. General information

NPI: 1679400899
Provider Name (Legal Business Name): JASON MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4061 KARELIA ST
LOS ANGELES CA
90065-3307
US

IV. Provider business mailing address

1577 E CHEVY CHASE DR STE 110
GLENDALE CA
91206-4091
US

V. Phone/Fax

Practice location:
  • Phone: 323-309-9919
  • Fax:
Mailing address:
  • Phone: 323-309-9919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number51739
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: