Healthcare Provider Details

I. General information

NPI: 1124334107
Provider Name (Legal Business Name): GOLDEN STATE SPORTS INJURY AND ORTHOPEDIC MEDICAL ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2010
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18531 ROSCOE BLVD STE 202
NORTHRIDGE CA
91324-5950
US

IV. Provider business mailing address

2980 N BEVERLY GLEN CIR SUITE 100
LOS ANGELES CA
90077-1726
US

V. Phone/Fax

Practice location:
  • Phone: 818-998-8400
  • Fax:
Mailing address:
  • Phone: 310-474-9809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: RONALD PERELMAN
Title or Position: OWNER
Credential: M.D.
Phone: 818-998-8400