=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528344686
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGELES MEDICAL CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2011
-----------------------------------------------------
Last Update Date | 09/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 E PICO BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90015-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-457-4000
-----------------------------------------------------
Fax | 213-457-6000
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 299
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90213-0299
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-457-4000
-----------------------------------------------------
Fax | 213-457-6000
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SARVENAZ SAADAT MOBASSER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 213-457-4000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A104717
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------