Healthcare Provider Details

I. General information

NPI: 1659641702
Provider Name (Legal Business Name): JONATHAN LEONARD BRAND, M.D., A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2012
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 E IMPERIAL HWY
LYNWOOD CA
90262-2636
US

IV. Provider business mailing address

4314 MARINA CITY DR SUITE 1118CTS
MARINA DEL REY CA
90292-5816
US

V. Phone/Fax

Practice location:
  • Phone: 310-701-7830
  • Fax: 310-645-5532
Mailing address:
  • Phone: 310-306-6150
  • Fax: 310-645-5532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberG50045
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. JONATHAN LEONARD BRAND
Title or Position: OWNER
Credential: M. D.
Phone: 310-306-6150