Healthcare Provider Details

I. General information

NPI: 1780141333
Provider Name (Legal Business Name): PAUL R BACKLUND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 SCHRADER BLVD
LOS ANGELES CA
90028-6213
US

IV. Provider business mailing address

1625 SCHRADER BLVD
LOS ANGELES CA
90028-6213
US

V. Phone/Fax

Practice location:
  • Phone: 323-821-3758
  • Fax:
Mailing address:
  • Phone: 323-821-3758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: