1487987905 NPI number — WILSHIRE MULTI-SPECIALTY CLINIC

Table of content: (NPI 1487987905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487987905 NPI number — WILSHIRE MULTI-SPECIALTY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILSHIRE MULTI-SPECIALTY CLINIC
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:
1487987905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3540 WILSHIRE BLVD
Provider Second Line Business Mailing Address:
STE: 1028
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90010-2307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-388-3712
Provider Business Mailing Address Fax Number:
213-388-0734

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3540 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
STE: 1028
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90010-2307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-388-3712
Provider Business Practice Location Address Fax Number:
213-388-0734
Provider Enumeration Date:
09/16/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RUDRAPPA
Authorized Official First Name:
KUSUM
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
213-388-3712

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  G87522 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS1201X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0010X , with the licence number: A37070 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: A54260 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: G36302 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P2900X , with the licence number: PSY12331 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: A37070 , 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)