Provider Demographics
NPI:1992127468
Name:SPINAL PROCEDURES MEDICAL GROUP
Entity type:Organization
Organization Name:SPINAL PROCEDURES MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PAYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:VAHEDIFAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-986-0200
Mailing Address - Street 1:17525 VENTURA BLVD
Mailing Address - Street 2:STE 203
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-5109
Mailing Address - Country:US
Mailing Address - Phone:818-986-0200
Mailing Address - Fax:818-638-5762
Practice Address - Street 1:17525 VENTURA BLVD
Practice Address - Street 2:STE 203
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-5109
Practice Address - Country:US
Practice Address - Phone:818-986-0200
Practice Address - Fax:818-638-5762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63617261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain