1275648735 NPI number — LOS ANGELES PM & R MEDICAL GROUP INC

Table of content: MRS. MADONNA MARIA LICHT LCSW LMHP (NPI 1760549885)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275648735 NPI number — LOS ANGELES PM & R MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOS ANGELES PM & R MEDICAL GROUP INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275648735
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
960 E GREEN ST
Provider Second Line Business Mailing Address:
SUITE 254
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91106-2412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-304-9060
Provider Business Mailing Address Fax Number:
626-304-9010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
289 W HUNTINGTON DR STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARCADIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91007-3490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-304-9060
Provider Business Practice Location Address Fax Number:
626-304-9010
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRITTON
Authorized Official First Name:
LIVA
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
626-304-9060

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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