1245653617 NPI number — MICHAEL W HANSEN OD INC

Table of content: (NPI 1245653617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245653617 NPI number — MICHAEL W HANSEN OD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICHAEL W HANSEN OD 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:
1245653617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 ROSECRANS AVE
Provider Second Line Business Mailing Address:
STE 1215
Provider Business Mailing Address City Name:
EL SEGUNDO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90245-4749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-321-6990
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
310 AVENUE I
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDONDO BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90277-5601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-373-3191
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HANSEN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
310-321-6990

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT11354TPL , 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)

  • Identifier: OPT11354TPL . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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