1982760500 NPI number — ERL MEDICAL CORPORATION

Table of content: (NPI 1982760500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982760500 NPI number — ERL MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERL MEDICAL CORPORATION
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:
LIM-KEITH MULTISPECIALTY MEDICAL CLINIC INC
Provider Other Organization Name Type Code:
3
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:
1982760500
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6200 WILSHIRE BLVD
Provider Second Line Business Mailing Address:
STE 1510
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90048-5801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-964-1440
Provider Business Mailing Address Fax Number:
323-937-5283

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6200 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
STE 1510
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90048-5801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-964-1440
Provider Business Practice Location Address Fax Number:
323-937-5283
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LIM
Authorized Official First Name:
EMMANUEL
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT/ MEDICAL DIRECTOR
Authorized Official Telephone Number:
323-964-1440

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X , with the licence number:  A43525 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 1262270001 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GR0072070 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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