MEDICARE: CLIFFORD I IRIELE MD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	A102130	CA

General Provider Information

NPI Number	:	1154628493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLIFFORD I IRIELE MD INC

Provider Business Mailing Address
First Line	:	PO BOX 34819
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-0819
Country	:	US
Telephone Number	:	213-483-0246
Fax Number	:	213-483-0249

Provider Business Practice Location Address
First Line	:	1711 W TEMPLE ST
Second Line	:	SUITE 6642
City	:	LOS ANGELES
State	:	CA
Zip	:	90026-5421
Country	:	US
Telephone Number	:	213-483-0246
Fax Number	:	213-483-0249

Authorized Official
Title or Position	:	OWNER
Name	:	CLIFFORD IFEANYI IRIELE
Credential	:	MD
Telephone Number	:	213-483-0246

Provider Enumeration Date	:	02/23/2011
Last Update Date	:	02/23/2011

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