=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124350129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOHO MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2010
-----------------------------------------------------
Last Update Date | 02/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11490 BURBANK BLVD STE 1C
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91601-2391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-509-0545
-----------------------------------------------------
Fax | 818-863-1812
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11490 BURBANK BLVD STE 1C
-----------------------------------------------------
City | NORTH HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91601-2391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-509-0545
-----------------------------------------------------
Fax | 818-863-1812
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HOWARD PFUPAJENA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-509-0545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G29345
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------