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General NPI Number Information
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NPI Number | 1043642358
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Entity Type | Organization
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Legal Business Name | PORTER RANCH INTEGRATIVE MEDICAL CLINIC, A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 08/08/2013
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Last Update Date | 08/08/2013
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Provider Practice Location Address
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Address Line | 11177 TAMPA AVE STE A
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City | PORTER RANCH
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State | CA
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Zip | 91326-2254
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Country | US
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Telephone | 818-831-8000
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Fax | 818-831-8005
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Provider Business Mailing Address
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Address Line | 11177 TAMPA AVE STE A
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City | PORTER RANCH
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State | CA
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Zip | 91326-2254
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Country | US
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Telephone | 818-831-8000
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Fax | 818-831-8005
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | DR. BENNETT ANNAN
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Credential | ED.D.
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Telephone | 818-831-8000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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