Healthcare Provider Details

I. General information

NPI: 1114190584
Provider Name (Legal Business Name): CLINICAL IMMUNOLOGY AND IGE MEDICAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11645 WILSHIRE BLVD SUITE 1150
LOS ANGELES CA
90025-1708
US

IV. Provider business mailing address

11645 WILSHIRE BLVD SUITE 1150
LOS ANGELES CA
90025-1708
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-7978
  • Fax: 310-909-1911
Mailing address:
  • Phone: 310-828-7978
  • Fax: 310-909-1911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberG70424
License Number StateCA

VIII. Authorized Official

Name: DR. CATHY WEISS GREEN
Title or Position: OWNER
Credential: M.D.
Phone: 310-828-7978