=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558791251
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGELUS MEDICAL CLINIC MULTISPECIALTY GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2013
-----------------------------------------------------
Last Update Date | 11/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3444 WHITTIER BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90023-1708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-264-2670
-----------------------------------------------------
Fax | 323-264-5752
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3444 WHITTIER BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90023-1708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-264-2670
-----------------------------------------------------
Fax | 323-264-5752
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, SECRETARY
-----------------------------------------------------
Name | NEHZAT NIKAKHTAR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-264-2670
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------