Healthcare Provider Details

I. General information

NPI: 1306038062
Provider Name (Legal Business Name): VENUS SPECIALTY MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17075 DEVONSHIRE ST STE 208
NORTHRIDGE CA
91325-5408
US

IV. Provider business mailing address

17075 DEVONSHIRE ST STE 208
NORTHRIDGE CA
91325-5408
US

V. Phone/Fax

Practice location:
  • Phone: 818-217-4351
  • Fax: 818-217-4104
Mailing address:
  • Phone: 818-217-4351
  • Fax: 818-217-4104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: FARIBA JAVAHERIAN
Title or Position: DOCTOR
Credential: MD
Phone: 818-217-4351