=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861820623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PANORAMA MEDICAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2013
-----------------------------------------------------
Last Update Date | 10/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14526 ROSCOE BLVD SUITE 101
-----------------------------------------------------
City | PANORAMA CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91402-4176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-456-7918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14526 ROSCOE BLVD SUITE 101
-----------------------------------------------------
City | PANORAMA CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91402-4176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-456-7918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DAVID NIKNIA
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 818-456-7918
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------