Healthcare Provider Details

I. General information

NPI: 1336249978
Provider Name (Legal Business Name): ETHAN M KREISWIRTH MA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAL STATE DOMINGUEZ HLS 1000 E. VICTORIA ST.
CARSON CA
90747-0001
US

IV. Provider business mailing address

5361 W 126TH ST
HAWTHORNE CA
90250-4128
US

V. Phone/Fax

Practice location:
  • Phone: 310-243-3894
  • Fax:
Mailing address:
  • Phone: 310-243-3894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: