Healthcare Provider Details

I. General information

NPI: 1326726076
Provider Name (Legal Business Name): MINDFIELD MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/11/2023
Certification Date: 07/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 SAN VICENTE BLVD STE 510
LOS ANGELES CA
90048-5455
US

IV. Provider business mailing address

1138 S CRESCENT HEIGHTS BLVD
LOS ANGELES CA
90035-2635
US

V. Phone/Fax

Practice location:
  • Phone: 310-658-4008
  • Fax:
Mailing address:
  • Phone: 310-658-4008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State

VIII. Authorized Official

Name: EDWARD J BATES
Title or Position: SECRETARY
Credential:
Phone: 310-658-4008