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General NPI Number Information
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NPI Number | 1184370199
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Entity Type | Organization
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Legal Business Name | ACTIVE MOBILE MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 02/28/2022
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Last Update Date | 03/18/2022
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Provider Practice Location Address
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Address Line | 3450 WILSHIRE BLVD STE 1200
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City | LOS ANGELES
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State | CA
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Zip | 90010-2214
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Country | US
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Telephone | 213-465-2643
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Fax | 213-232-4944
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Provider Business Mailing Address
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Address Line | 3325 WILSHIRE BLVD STE 208
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City | LOS ANGELES
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State | CA
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Zip | 90010-1733
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Country | US
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Telephone | 213-465-2643
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Fax | 213-232-4944
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | JOANNA BALASICO
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Credential | RN
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Telephone | 213-465-2643
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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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 | 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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