Provider Demographics
NPI:1396289864
Name:INFINITI MEDICAL GROUP INC
Entity type:Organization
Organization Name:INFINITI MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALVA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:818-646-1610
Mailing Address - Street 1:14407 HAMLIN ST
Mailing Address - Street 2:UNIT B
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91401-6228
Mailing Address - Country:US
Mailing Address - Phone:818-646-1610
Mailing Address - Fax:818-646-1630
Practice Address - Street 1:14407 HAMLIN ST
Practice Address - Street 2:UNIT B
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-6228
Practice Address - Country:US
Practice Address - Phone:818-646-1610
Practice Address - Fax:818-646-1630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-18
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Multi-Specialty