Healthcare Provider Details

I. General information

NPI: 1962874131
Provider Name (Legal Business Name): MIRACLE MILE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2015
Last Update Date: 10/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6221 WILSHIRE BLVD SUITE 215
LOS ANGELES CA
90048-5201
US

IV. Provider business mailing address

6221 WILSHIRE BLVD SUITE 215
LOS ANGELES CA
90048-5201
US

V. Phone/Fax

Practice location:
  • Phone: 323-938-7294
  • Fax: 323-954-9295
Mailing address:
  • Phone: 323-938-7294
  • Fax: 323-954-9295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA71831
License Number StateCA

VIII. Authorized Official

Name: DR. MONICA ASNANI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 323-938-7294