Healthcare Provider Details

I. General information

NPI: 1851565337
Provider Name (Legal Business Name): CITIZENS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 04/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11560 W. PICO BLVD
WEST LOS ANGELES CA
90064
US

IV. Provider business mailing address

11560 W. PICO BLVD
WEST LOS ANGELES CA
90064
US

V. Phone/Fax

Practice location:
  • Phone: 310-477-8285
  • Fax: 310-477-9642
Mailing address:
  • Phone: 310-477-8285
  • Fax: 310-477-9642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG29636
License Number StateCA

VIII. Authorized Official

Name: LARRY BRANDIS
Title or Position: DOCTOR
Credential:
Phone: 310-477-8285