Healthcare Provider Details

I. General information

NPI: 1679730923
Provider Name (Legal Business Name): TOTAL REHABILITATION MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 CAHUENGA BLVD
NORTH HOLLYWOOD CA
91601-2104
US

IV. Provider business mailing address

1407 HILLSIDE DR
GLENDALE CA
91208-2416
US

V. Phone/Fax

Practice location:
  • Phone: 818-308-7450
  • Fax: 818-308-7795
Mailing address:
  • Phone: 818-547-9870
  • Fax: 818-547-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 12456
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberMTA44130
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA97751
License Number StateCA

VIII. Authorized Official

Name: DR. ALIASGHAR MATIN
Title or Position: DIRECTOR
Credential: MD
Phone: 818-547-9870