1326178245 NPI number — MAMMOTH LAKES ORTHOPEDICS ASSOCIATES

Table of content: (NPI 1326178245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326178245 NPI number — MAMMOTH LAKES ORTHOPEDICS ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAMMOTH LAKES ORTHOPEDICS ASSOCIATES
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:
1326178245
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23600 TELO AVE
Provider Second Line Business Mailing Address:
SUITE #180
Provider Business Mailing Address City Name:
TORRANCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90505-4035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-257-1500
Provider Business Mailing Address Fax Number:
310-257-1506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
452 OLD MAMMOTH ROAD
Provider Second Line Business Practice Location Address:
SUITE R
Provider Business Practice Location Address City Name:
MAMMOTH LAKES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93546-5021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-924-8688
Provider Business Practice Location Address Fax Number:
760-924-8688
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STRIPLIN
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
BRIAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
310-508-7638

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G075766 , 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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