Healthcare Provider Details

I. General information

NPI: 1407557960
Provider Name (Legal Business Name): VINCENT POGO HEALTH OF NV PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26342 FAIRSIDE RD
MALIBU CA
90265-2927
US

IV. Provider business mailing address

2287 MULHOLLAND HWY #526
CALABASAS CA
90290
US

V. Phone/Fax

Practice location:
  • Phone: 805-975-5006
  • Fax:
Mailing address:
  • Phone: 805-975-0006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: NATALIE MALONEY
Title or Position: COO
Credential:
Phone: 805-975-0006