Healthcare Provider Details

I. General information

NPI: 1689849481
Provider Name (Legal Business Name): LADERA MEDICAL PRACTICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5141 CRENSHAW BLVD
LOS ANGELES CA
90043-1853
US

IV. Provider business mailing address

5141 CRENSHAW BLVD
LOS ANGELES CA
90043-1853
US

V. Phone/Fax

Practice location:
  • Phone: 323-545-9288
  • Fax: 323-545-9287
Mailing address:
  • Phone: 323-545-9288
  • Fax: 323-545-9287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. DEEDEE WESTON
Title or Position: DIRECTOR
Credential:
Phone: 323-545-9288