Healthcare Provider Details

I. General information

NPI: 1376312074
Provider Name (Legal Business Name): SHORE ORTHOPEDICS A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2023
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4551 GLENCOE AVE STE 145
MARINA DEL REY CA
90292-6385
US

IV. Provider business mailing address

2009 FAYMONT AVE
MANHATTAN BEACH CA
90266-4150
US

V. Phone/Fax

Practice location:
  • Phone: 949-988-7800
  • Fax:
Mailing address:
  • Phone: 617-686-7177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BRETT SHORE
Title or Position: OWNER
Credential: MD
Phone: 617-686-7177