Healthcare Provider Details

I. General information

NPI: 1639494206
Provider Name (Legal Business Name): PHOENIX DIAGNOSTIC MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20301 VENTURA BLVD STE 105
WOODLAND HILLS CA
91364-2447
US

IV. Provider business mailing address

22361 PACIFIC COAST HWY # 441
MALIBU CA
90265-4879
US

V. Phone/Fax

Practice location:
  • Phone: 310-871-3434
  • Fax:
Mailing address:
  • Phone: 310-871-3434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberG29768
License Number StateCA

VIII. Authorized Official

Name: DR. STEVEN KAYE
Title or Position: OWNER
Credential: M.D.
Phone: 310-871-3434