Healthcare Provider Details

I. General information

NPI: 1467987222
Provider Name (Legal Business Name): SEPULVEDA PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8632 S SEPULVEDA BLVD
WESTCHESTER CA
90045-4015
US

IV. Provider business mailing address

8632 S SEPULVEDA BLVD
WESTCHESTER CA
90045-4015
US

V. Phone/Fax

Practice location:
  • Phone: 310-348-8298
  • Fax: 310-348-8299
Mailing address:
  • Phone: 310-348-8298
  • Fax: 310-348-8299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number223474076
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number800326306
License Number StateCA

VIII. Authorized Official

Name: GEORGE HARRAKA
Title or Position: OWNER
Credential: DC
Phone: 310-348-8298