Provider Demographics
NPI:1063513455
Name:FUNCTIONAL RESTORATION MEDICAL CENTER, INC,
Entity type:Organization
Organization Name:FUNCTIONAL RESTORATION MEDICAL CENTER, INC,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MOOSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEIKALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-432-1000
Mailing Address - Street 1:9134 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-3540
Mailing Address - Country:US
Mailing Address - Phone:310-432-1000
Mailing Address - Fax:310-432-4321
Practice Address - Street 1:4316 SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90270-2838
Practice Address - Country:US
Practice Address - Phone:323-771-9867
Practice Address - Fax:323-771-2083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13197BMedicare ID - Type Unspecified