Healthcare Provider Details

I. General information

NPI: 1386084846
Provider Name (Legal Business Name): LAX PHYSICAL MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 S SEPULVEDA BLVD SUITE 104
LOS ANGELES CA
90045-4849
US

IV. Provider business mailing address

9100 S SEPULVEDA BLVD SUITE 104
LOS ANGELES CA
90045-4849
US

V. Phone/Fax

Practice location:
  • Phone: 310-670-9999
  • Fax: 310-670-9994
Mailing address:
  • Phone: 310-670-9999
  • Fax: 310-670-9994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA101415
License Number StateCA

VIII. Authorized Official

Name: DR. SHELLEY MCDONALD
Title or Position: PRESIDENT
Credential: MD
Phone: 310-670-9999