Healthcare Provider Details

I. General information

NPI: 1265475016
Provider Name (Legal Business Name): ROSS ALAN BODLE MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD BUILDING 500, 2 EAST A/D
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

2147 EWING ST
LOS ANGELES CA
90039-3920
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-3711
  • Fax:
Mailing address:
  • Phone: 310-477-3711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number39730
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: