=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407304439
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER ORTHOPAEDIC TRAUMA SPECIALISTS, PMC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2016
-----------------------------------------------------
Last Update Date | 02/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 E ARTESIA ST STE 255
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91767-2921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-596-4346
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 160 E ARTESIA ST STE 255
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91767-2921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-596-4346
-----------------------------------------------------
Fax | 909-596-4344
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | HRAYR G BASMAJIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-596-4346
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------