1023401585 NPI number — LOS ANGELES SHOULDER INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023401585 NPI number — LOS ANGELES SHOULDER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOS ANGELES SHOULDER 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:
1023401585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2351 OCEAN VIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIGNAL HILL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90755-3778
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-546-3461
Provider Business Mailing Address Fax Number:
310-798-8231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 S SEPULVEDA BLVD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
MANHATTAN BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90266-6814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-546-3461
Provider Business Practice Location Address Fax Number:
310-798-8231
Provider Enumeration Date:
03/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HARTSHORN
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
AUGUST
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-546-3461

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  A107628 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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