1396038642 NPI number — SMILE PEDIATRIC THERAPY AND DIAGNOSTICS

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 1396038642 NPI number — SMILE PEDIATRIC THERAPY AND DIAGNOSTICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMILE PEDIATRIC THERAPY AND DIAGNOSTICS
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:
1396038642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 W SUNSET BLVD
Provider Second Line Business Mailing Address:
SUITE 510
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90027-5861
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-644-9380
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5000 W SUNSET BLVD
Provider Second Line Business Practice Location Address:
SUITE 510
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90027-5861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-644-9380
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HAJJAR
Authorized Official First Name:
DANIELLE
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
SPEECH PATHOLOGIST
Authorized Official Telephone Number:
323-644-9380

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X , with the licence number:  18892 , 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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