MEDICARE: UNIVERSITY SPINE & PAIN CENTER

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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	A95636	CA

General Provider Information

NPI Number	:	1922435411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY SPINE & PAIN CENTER

Provider Business Mailing Address
First Line	:	555 PIER AVE
Second Line	:	SUITE 1
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-3839
Country	:	US
Telephone Number	:	424-488-0500
Fax Number	:	424-488-0498

Provider Business Practice Location Address
First Line	:	555 PIER AVE
Second Line	:	SUITE 1
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-3839
Country	:	US
Telephone Number	:	424-488-0500
Fax Number	:	424-488-0498

Authorized Official
Title or Position	:	CEO
Name	:	DR. BAO NGUYEN
Credential	:	M.D.
Telephone Number	:	714-254-5751

Provider Enumeration Date	:	09/30/2013
Last Update Date	:	06/30/2014

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