Healthcare Provider Details

I. General information

NPI: 1699175364
Provider Name (Legal Business Name): RAND SCHRADER 5P21 CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 08/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N MISSION RD
LOS ANGELES CA
90033-1021
US

IV. Provider business mailing address

811 S WILTON PL APT 7
LOS ANGELES CA
90005-3544
US

V. Phone/Fax

Practice location:
  • Phone: 323-343-8255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number272539
License Number StateCA

VIII. Authorized Official

Name: LANOMAY BENJAMIN
Title or Position: NURSE MANAGER
Credential: RN
Phone: 323-343-8255