Provider Demographics
NPI:1194970087
Name:HERITAGE ORTHOPEDIC AND INDUSTRIAL MEDICINE MULTISPECIALTY MEDICINE
Entity type:Organization
Organization Name:HERITAGE ORTHOPEDIC AND INDUSTRIAL MEDICINE MULTISPECIALTY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-705-7200
Mailing Address - Street 1:17750 SHERMAN WAY
Mailing Address - Street 2:STE: 100
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-3380
Mailing Address - Country:US
Mailing Address - Phone:818-705-7200
Mailing Address - Fax:818-342-8567
Practice Address - Street 1:17750 SHERMAN WAY
Practice Address - Street 2:STE: 100
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-3380
Practice Address - Country:US
Practice Address - Phone:818-705-7200
Practice Address - Fax:818-342-8567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62809111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty