Provider Demographics
NPI:1912443490
Name:GENESIS FUNCTIONAL RESTORATION CLINIC INC
Entity type:Organization
Organization Name:GENESIS FUNCTIONAL RESTORATION CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMRON
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:HAKHAMIMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-697-2330
Mailing Address - Street 1:191 S BUENA VISTA ST
Mailing Address - Street 2:335
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:191 S BUENA VISTA ST
Practice Address - Street 2:335
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4554
Practice Address - Country:US
Practice Address - Phone:323-697-2330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty