Provider Demographics
NPI:1427325109
Name:CA FIDELIS PC
Entity type:Organization
Organization Name:CA FIDELIS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HALVORSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:877-408-2488
Mailing Address - Street 1:11726 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 414
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5044
Mailing Address - Country:US
Mailing Address - Phone:877-408-2488
Mailing Address - Fax:866-776-6641
Practice Address - Street 1:11726 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 414
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5044
Practice Address - Country:US
Practice Address - Phone:877-408-2488
Practice Address - Fax:866-776-6641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75477208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty