Healthcare Provider Details

I. General information

NPI: 1073055570
Provider Name (Legal Business Name): MEDICAL SUPPORT LOS ANGELES A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N PRAIRIE AVE SUITE #201
INGLEWOOD CA
90301-4507
US

IV. Provider business mailing address

1294 E COLORADO BLVD
PASADENA CA
91106-1901
US

V. Phone/Fax

Practice location:
  • Phone: 310-674-4419
  • Fax: 310-674-6689
Mailing address:
  • Phone: 626-407-2152
  • Fax: 626-239-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number
License Number State

VIII. Authorized Official

Name: SAHNIAH SICIARZ-LAMBERT
Title or Position: CFO
Credential:
Phone: 626-407-2152