Healthcare Provider Details

I. General information

NPI: 1093148652
Provider Name (Legal Business Name): MARY LOU RANE PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2013
Last Update Date: 08/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10332 EASTBORNE AVE
LOS ANGELES CA
90024-5350
US

IV. Provider business mailing address

10332 EASTBORNE AVE
LOS ANGELES CA
90024-5350
US

V. Phone/Fax

Practice location:
  • Phone: 310-277-0241
  • Fax: 310-277-9604
Mailing address:
  • Phone: 310-277-0241
  • Fax: 310-277-9604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number133N00000X
License Number State

VIII. Authorized Official

Name: MARY LOU RANE
Title or Position: DOCTOR
Credential: PHD
Phone: 310-277-0241