Healthcare Provider Details

I. General information

NPI: 1447708987
Provider Name (Legal Business Name): SHERMAN OAKS PAIN AND SPINE INSTITUTE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4911 VAN NUYS BLVD STE 307
SHERMAN OAKS CA
91403-1751
US

IV. Provider business mailing address

4533 VISTA DEL MONTE AVE APT. 206
SHERMAN OAKS CA
91403-3031
US

V. Phone/Fax

Practice location:
  • Phone: 818-638-1159
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA135166
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: YASHAR ILKHCHOUI
Title or Position: CEO, PRESIDENT
Credential:
Phone: 818-638-1159