Healthcare Provider Details

I. General information

NPI: 1124269717
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 11/02/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4580 ELECTRONICS PL
LOS ANGELES CA
90039-1008
US

IV. Provider business mailing address

393 E WALNUT ST 3RD FLOOR PHR GROUP & PROVIDER ENROLLMENT
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 818-502-5141
  • Fax:
Mailing address:
  • Phone: 626-405-7914
  • Fax: 626-405-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. RAMIN DAVIDOFF
Title or Position: EXECUTIVE MEDICAL DIRECTOR
Credential: M.D.
Phone: 877-608-0044