Healthcare Provider Details

I. General information

NPI: 1306342415
Provider Name (Legal Business Name): LOS ANGELES SPORTS INSTITUTE AND PHYSICAL THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12811 VICTORY BLVD
NORTH HOLLYWOOD CA
91606-3012
US

IV. Provider business mailing address

12811 VICTORY BLVD
NORTH HOLLYWOOD CA
91606-3012
US

V. Phone/Fax

Practice location:
  • Phone: 818-747-4189
  • Fax:
Mailing address:
  • Phone: 818-747-4189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number37937
License Number StateCA

VIII. Authorized Official

Name: JOSHUA MAZALIAN
Title or Position: CEO
Credential:
Phone: 818-747-4189