Healthcare Provider Details

I. General information

NPI: 1164777645
Provider Name (Legal Business Name): MARC LIPTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

135 E HOLLY ST 104
PASADENA CA
91103-3941
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number755631
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: