Healthcare Provider Details

I. General information

NPI: 1275191082
Provider Name (Legal Business Name): ENNEAGON HEALTH, APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12922 VICTORY BLVD
NORTH HOLLYWOOD CA
91606-2924
US

IV. Provider business mailing address

12652 W SUNSET BLVD
LOS ANGELES CA
90049-3831
US

V. Phone/Fax

Practice location:
  • Phone: 310-779-2289
  • Fax:
Mailing address:
  • Phone: 310-779-2289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: AYDIN POOLI
Title or Position: PRESIDENT AND CEO
Credential: MD
Phone: 310-779-2289