Healthcare Provider Details

I. General information

NPI: 1790611192
Provider Name (Legal Business Name): MR. MICHAEL LENARDO PAYNE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 LOS FELIZ BLVD # 1
LOS ANGELES CA
90027-2215
US

IV. Provider business mailing address

4316 LOS FELIZ BLVD # 1
LOS ANGELES CA
90027-2215
US

V. Phone/Fax

Practice location:
  • Phone: 805-210-4001
  • Fax:
Mailing address:
  • Phone: 805-210-4001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberE151623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: