Healthcare Provider Details

I. General information

NPI: 1679711022
Provider Name (Legal Business Name): SOUTHERN LOS ANGELES COUNTY ANESTHESIA MEDICAL GROUP INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2009
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 E OCEAN BLVD APT# 930
LONG BEACH CA
90803-2545
US

IV. Provider business mailing address

PO BOX 7001
TARZANA CA
91357-7001
US

V. Phone/Fax

Practice location:
  • Phone: 562-221-9071
  • Fax:
Mailing address:
  • Phone: 818-888-7815
  • Fax: 818-715-1722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number20A9358
License Number StateCA

VIII. Authorized Official

Name: CASPER YOUNG
Title or Position: SOLE OWNER
Credential: D.O.
Phone: 818-888-7815