Healthcare Provider Details

I. General information

NPI: 1447539523
Provider Name (Legal Business Name): OAC SOUTHERN MEDICAL PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 07/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23430 HAWTHORNE BLVD 125
TORRANCE CA
90505-4720
US

IV. Provider business mailing address

23430 HAWTHORNE BLVD 125
TORRANCE CA
90505-4720
US

V. Phone/Fax

Practice location:
  • Phone: 310-373-0555
  • Fax: 310-373-5655
Mailing address:
  • Phone: 310-373-0555
  • Fax: 310-373-5655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number005474
License Number StateCA

VIII. Authorized Official

Name: DR. MARYAM RAHIMI
Title or Position: DOCTOR
Credential: D.O.
Phone: 310-373-0555