=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750771077
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANCHO CUCAMONGA ORTHOPEDIC PAIN MANAGEMENT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2015
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8599 HAVEN AVE STE 104
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-4849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-980-0917
-----------------------------------------------------
Fax | 888-416-6865
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16952 VENTURA BLVD
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-4197
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-789-3964
-----------------------------------------------------
Fax | 818-789-3967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. PEJMAN E. SHIRAZY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 818-789-3964
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | A76100
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------