=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023757275
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRAINLAB MEDICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2022
-----------------------------------------------------
Last Update Date | 09/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27509 AGOURA RD STE 205
-----------------------------------------------------
City | AGOURA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91301-5149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-791-3205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27489 AGOURA RD STE 101
-----------------------------------------------------
City | AGOURA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91301-2481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | DR. ABRAHAM MALKIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 818-839-7556
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------