Healthcare Provider Details

I. General information

NPI: 1760676563
Provider Name (Legal Business Name): AMIGO INDUSTRIAL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 COLDWATER CANYON AVE STE 1E
NORTH HOLLYWOOD CA
91605-5167
US

IV. Provider business mailing address

13029A VICTORY BLVD # 525
NORTH HOLLYWOOD CA
91606-2925
US

V. Phone/Fax

Practice location:
  • Phone: 818-759-2555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberG84264
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License NumberG84264
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG84264
License Number StateCA

VIII. Authorized Official

Name: DR. ROBERE J MISSIRIAN
Title or Position: PRESIDENT
Credential: MD
Phone: 818-759-2555