Healthcare Provider Details

I. General information

NPI: 1073612982
Provider Name (Legal Business Name): WESTSIDE PRIMARY CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 05/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2428 SANTA MONICA BLVD
SANTA MONICA CA
90404
US

IV. Provider business mailing address

9613 KIRKSIDE ROAD
LA CA
90035
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-3385
  • Fax: 310-828-6635
Mailing address:
  • Phone: 310-838-8842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberA78716
License Number StateCA

VIII. Authorized Official

Name: ROMANA HAIDER
Title or Position: M.D.
Credential:
Phone: 310-829-3385