Healthcare Provider Details

I. General information

NPI: 1992218101
Provider Name (Legal Business Name): REDONDO BEACH PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N PACIFIC COAST HWY STE 101
REDONDO BEACH CA
90277-2162
US

IV. Provider business mailing address

901 N PACIFIC COAST HWY STE 101
REDONDO BEACH CA
90277-2162
US

V. Phone/Fax

Practice location:
  • Phone: 310-379-3303
  • Fax:
Mailing address:
  • Phone: 310-379-3303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA118026
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNPF95007657
License Number StateCA

VIII. Authorized Official

Name: DR. IVAN SANCHEZ
Title or Position: MANAGER
Credential: DC
Phone: 310-379-3303