Healthcare Provider Details

I. General information

NPI: 1659414258
Provider Name (Legal Business Name): REPHANA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 15TH ST STE 402
SANTA MONICA CA
90404-1813
US

IV. Provider business mailing address

5850 W 3RD ST # 132
LOS ANGELES CA
90036-2860
US

V. Phone/Fax

Practice location:
  • Phone: 310-451-0111
  • Fax:
Mailing address:
  • Phone: 310-451-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA64647
License Number StateCA

VIII. Authorized Official

Name: NEAL SHANBLATT
Title or Position: PRESIDENT
Credential: MD
Phone: 310-451-0111