Healthcare Provider Details

I. General information

NPI: 1003520065
Provider Name (Legal Business Name): FMC 26, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 01/12/2023
Certification Date: 01/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14547 VICTORY BLVD
VAN NUYS CA
91411-1619
US

IV. Provider business mailing address

14547 VICTORY BLVD
VAN NUYS CA
91411-1619
US

V. Phone/Fax

Practice location:
  • Phone: 818-997-3232
  • Fax: 818-997-7750
Mailing address:
  • Phone: 818-997-3232
  • Fax: 818-997-7750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOABB MARIE GRIPPO
Title or Position: BILLING MANAGER
Credential:
Phone: 909-967-5670