1972560563 NPI number — SMENSA MEDICAL GROUP, PC

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 1972560563 NPI number — SMENSA MEDICAL GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMENSA MEDICAL GROUP, PC
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:
1972560563
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:
PO BOX 1698
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INGLEWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90308-1698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-673-6581
Provider Business Mailing Address Fax Number:
310-419-4493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 E HARDY ST
Provider Second Line Business Practice Location Address:
SUITE 222
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90301-4106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-673-6581
Provider Business Practice Location Address Fax Number:
310-419-4493
Provider Enumeration Date:
04/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCOTT
Authorized Official First Name:
CRANFORD
Authorized Official Middle Name:
LAVERN
Authorized Official Title or Position:
PRESIDENT / MEDICAL DIRECTOR
Authorized Official Telephone Number:
310-673-6581

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  C32142 , 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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