Healthcare Provider Details

I. General information

NPI: 1548309560
Provider Name (Legal Business Name): SHANE MEDICAL OFFICE A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 E. SLAUSON AVE
MAYWOOD CA
90270
US

IV. Provider business mailing address

P.O. BOX 413
PACIFIC PALISADES CA
90272
US

V. Phone/Fax

Practice location:
  • Phone: 323-773-2020
  • Fax: 323-771-6069
Mailing address:
  • Phone: 323-773-2020
  • Fax: 323-771-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA48800
License Number StateCA

VIII. Authorized Official

Name: MRS. TARA PAJOUM II
Title or Position: OFFICE MANAGER
Credential:
Phone: 323-773-2020