Healthcare Provider Details

I. General information

NPI: 1669831459
Provider Name (Legal Business Name): INSTITUTE OF DIAGNOSITC MEDICINE & RESEARCH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 S LOS ROBLES AVE
PASADENA CA
91106-3716
US

IV. Provider business mailing address

833 S LOS ROBLES AVE
PASADENA CA
91106-3716
US

V. Phone/Fax

Practice location:
  • Phone: 310-592-5067
  • Fax: 714-996-9267
Mailing address:
  • Phone: 310-592-5067
  • Fax: 714-996-9267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. KHASHAYAR POURMAND
Title or Position: CEO
Credential:
Phone: 310-592-5067