Healthcare Provider Details

I. General information

NPI: 1427441567
Provider Name (Legal Business Name): DANIEL IMOESIRI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18926 WYANDOTTE ST
RESEDA CA
91335-2658
US

IV. Provider business mailing address

PO BOX 572362
TARZANA CA
91357-2362
US

V. Phone/Fax

Practice location:
  • Phone: 818-629-8678
  • Fax:
Mailing address:
  • Phone: 818-629-8678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number197608906
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: