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General NPI Number Information
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NPI Number | 1407869928
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Entity Type | Organization
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Legal Business Name | GREAT SPIRIT MEDICAL GROUP,INC
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Dates
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Enumeration Date | 08/14/2006
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Last Update Date | 11/12/2007
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Provider Practice Location Address
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Address Line | 9900 BALBOA BLVD SUITE A
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City | NORTHRIDGE
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State | CA
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Zip | 91325-5403
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Country | US
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Telephone | 818-701-0017
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Fax | 818-701-0073
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Provider Business Mailing Address
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Address Line | 9900 BALBOA BLVD SUITE A
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City | NORTHRIDGE
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State | CA
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Zip | 91325-5403
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Country | US
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Telephone | 818-701-0017
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Fax | 818-701-0073
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. CONRADO J.R MIRANDA IV
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Credential | MD
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Telephone | 818-701-0017
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A48817
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License Number State | CA
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