Healthcare Provider Details

I. General information

NPI: 1558316984
Provider Name (Legal Business Name): LA PHYSIATRISTS PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 WILSHIRE BLVD SUITE 403
LOS ANGELES CA
90017-4810
US

IV. Provider business mailing address

1245 WILSHIRE BLVD SUITE 403
LOS ANGELES CA
90017-4810
US

V. Phone/Fax

Practice location:
  • Phone: 213-482-1046
  • Fax: 213-482-4811
Mailing address:
  • Phone: 213-482-1046
  • Fax: 213-482-4811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JORGE DAMIAN MINOR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 213-482-1046