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General NPI Number Information
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NPI Number | 1528586096
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Entity Type | Organization
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Legal Business Name | ENDEAVOR MEDICAL GROUP
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Dates
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Enumeration Date | 09/06/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 20246 SATICOY ST STE 201
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City | WINNETKA
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State | CA
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Zip | 91306-4433
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Country | US
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Telephone | 818-812-9506
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Fax | 818-812-9508
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Provider Business Mailing Address
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Address Line | 20246 SITACOY STREET STE# 201
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City | WINNETKA
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State | CA
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Zip | 91306
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Country | US
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Telephone | 818-812-9506
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Fax | 818-812-9508
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | MR. TIMUR RUSLANOVICH POGODIN
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Credential | MD
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Telephone | 818-812-9506
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | A133706
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License Number State | CA
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