Healthcare Provider Details

I. General information

NPI: 1558869354
Provider Name (Legal Business Name): ADVANCE PAIN MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7230 MEDICAL CENTER DR STE 500
WEST HILLS CA
91307-4024
US

IV. Provider business mailing address

7230 MEDICAL CENTER DR STE 500
WEST HILLS CA
91307-4024
US

V. Phone/Fax

Practice location:
  • Phone: 818-348-7246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number741488
License Number StateCA

VIII. Authorized Official

Name: GINGER JOHNSON
Title or Position: DIRECTOR
Credential:
Phone: 818-348-7253