Healthcare Provider Details

I. General information

NPI: 1164777090
Provider Name (Legal Business Name): OAC SOUTHERN MEDICAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 W COAST HWY SUITE A
NEWPORT BEACH CA
92663-4007
US

IV. Provider business mailing address

23430 HAWTHORNE BLVD SUITE 125
TORRANCE CA
90505-4720
US

V. Phone/Fax

Practice location:
  • Phone: 949-209-0220
  • Fax: 949-270-5139
Mailing address:
  • Phone: 310-373-0555
  • Fax: 310-373-5655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number20A10143
License Number StateCA

VIII. Authorized Official

Name: MARYAM RAHIMI
Title or Position: PRESIDENT
Credential: D.O.
Phone: 310-634-1146