Healthcare Provider Details

I. General information

NPI: 1487667002
Provider Name (Legal Business Name): CARL LAURYSSEN MD PROF CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 BEVERLY BLVD STE 405
LOS ANGELES CA
90048-4505
US

IV. Provider business mailing address

8201 BEVERLY BLVD SUITE 405
LOS ANGELES CA
90048-4505
US

V. Phone/Fax

Practice location:
  • Phone: 323-272-4678
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberC50914
License Number StateCA

VIII. Authorized Official

Name: CARL LAURYSSEN
Title or Position: OWNER
Credential: M.D.
Phone: 310-358-2490