Healthcare Provider Details

I. General information

NPI: 1528265584
Provider Name (Legal Business Name): MOTION PICTURE AND TELEVISION FUND MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23388 MULHOLLAND DR MAILSTOP 260
WOODLAND HILLS CA
91364-2733
US

IV. Provider business mailing address

23388 MULHOLLAND DR MAILSTOP 260
WOODLAND HILLS CA
91364-2733
US

V. Phone/Fax

Practice location:
  • Phone: 818-876-1636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. SETH ELLIS
Title or Position: VP CHIEF OPERATING OFFICER
Credential:
Phone: 818-876-1079