Healthcare Provider Details

I. General information

NPI: 1013131796
Provider Name (Legal Business Name): INNOVATIVE DIAGNOSTIC MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 12/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 CENTURY PARK EAST SUITE 1040
LOS ANGELES CA
90067
US

IV. Provider business mailing address

1801 CENTURY PARK EAST SUITE 1040
LOS ANGELES CA
90067
US

V. Phone/Fax

Practice location:
  • Phone: 310-553-7980
  • Fax: 310-943-3279
Mailing address:
  • Phone: 310-553-7980
  • Fax: 310-943-3279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License NumberA44107
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA106704
License Number StateCA

VIII. Authorized Official

Name: SEAN ATAEE
Title or Position: MEDICAL DIRECTOR/OWNER
Credential: M.D.
Phone: 310-553-7960