Healthcare Provider Details

I. General information

NPI: 1205127693
Provider Name (Legal Business Name): PAN AMERICAN MOA FOUNDATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2011
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4533 S. CENTINELA AVENUE
LOS ANGELES CA
90066-6249
US

IV. Provider business mailing address

4533 S. CENTINELA AVENUE
LOS ANGELES CA
90066-6249
US

V. Phone/Fax

Practice location:
  • Phone: 310-574-9900
  • Fax: 310-574-9901
Mailing address:
  • Phone: 310-574-9900
  • Fax: 310-574-9901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number0002405889-0001-1
License Number StateCA

VIII. Authorized Official

Name: MR. RON C KATO
Title or Position: DIRECTOR/PRESIDENT
Credential:
Phone: 310-574-9900