Healthcare Provider Details

I. General information

NPI: 1063513455
Provider Name (Legal Business Name): FUNCTIONAL RESTORATION MEDICAL CENTER, INC,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 SLAUSON AVE
MAYWOOD CA
90270-2838
US

IV. Provider business mailing address

9134 W OLYMPIC BLVD
BEVERLY HILLS CA
90212-3540
US

V. Phone/Fax

Practice location:
  • Phone: 323-771-9867
  • Fax: 323-771-2083
Mailing address:
  • Phone: 310-432-1000
  • Fax: 310-432-4321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MOOSA HEIKALI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-432-1000