MEDICARE: PATIMA LIFE MEDICAL GROUP,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	207RG0300X	Geriatric Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1306142468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATIMA LIFE MEDICAL GROUP,INC

Provider Business Mailing Address
First Line	:	505 SHATTO PL
Second Line	:	200
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-1754
Country	:	US
Telephone Number	:	213-736-0450
Fax Number	:

Provider Business Practice Location Address
First Line	:	505 SHATTO PL
Second Line	:	200
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-1754
Country	:	US
Telephone Number	:	213-736-0450
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	RICHARD CHUNG
Credential	:
Telephone Number	:	213-736-0450

Provider Enumeration Date	:	02/07/2011
Last Update Date	:	02/07/2011

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