Healthcare Provider Details

I. General information

NPI: 1568689966
Provider Name (Legal Business Name): VALLEY PULMONARY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 05/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18546 ROSCOE BLVD STE 308
NORTHRIDGE CA
91324-4669
US

IV. Provider business mailing address

18546 ROSCOE BLVD STE 308
NORTHRIDGE CA
91324-4669
US

V. Phone/Fax

Practice location:
  • Phone: 818-349-2931
  • Fax: 818-349-7930
Mailing address:
  • Phone: 818-349-2931
  • Fax: 818-349-7930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG43200
License Number StateCA

VIII. Authorized Official

Name: DR. JEAN GRANT HAWKINS
Title or Position: OWNER
Credential: MD
Phone: 818-349-2931