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General NPI Number Information
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NPI Number | 1326564212
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Entity Type | Organization
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Legal Business Name | SUPERCLINIC PROFESSIONALS MEDICAL CORP A CALIFORNIA CORPORATION
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Dates
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Enumeration Date | 08/22/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 12134 VICTORY BLVD
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City | NORTH HOLLYWOOD
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State | CA
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Zip | 91606-3205
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Country | US
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Telephone | 818-762-8702
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Fax | 818-761-2583
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Provider Business Mailing Address
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Address Line | 12134 VICTORY BLVD
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City | NORTH HOLLYWOOD
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State | CA
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Zip | 91606-3205
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Country | US
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Telephone | 818-762-8702
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Fax | 818-761-2583
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. MITCHELL PAUL RUBIN
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Credential |
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Telephone | 818-762-8702
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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