Healthcare Provider Details

I. General information

NPI: 1952602526
Provider Name (Legal Business Name): IMMANUEL MEDICAL OFFICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2010
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18300 ROSCOE BLVD CENTER FOR REHAB NHMC
NORTHRIDGE CA
91325-4105
US

IV. Provider business mailing address

18300 ROSCOE BLVD CENTER FOR REHAB NHMC
NORTHRIDGE CA
91325-4105
US

V. Phone/Fax

Practice location:
  • Phone: 818-885-5342
  • Fax:
Mailing address:
  • Phone: 818-885-5342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: ALEX L LIN
Title or Position: MD
Credential:
Phone: 818-885-5342