Healthcare Provider Details

I. General information

NPI: 1326584277
Provider Name (Legal Business Name): HEALTH ATLAST WEST LA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2428 SANTA MONICA BLVD STE 308
SANTA MONICA CA
90404-2046
US

IV. Provider business mailing address

2428 SANTA MONICA BLVD STE 308
SANTA MONICA CA
90404-2046
US

V. Phone/Fax

Practice location:
  • Phone: 310-453-8393
  • Fax: 310-453-8696
Mailing address:
  • Phone: 310-453-8393
  • Fax: 310-453-8696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: WAYNE HIGASHI
Title or Position: OWNER
Credential: DC
Phone: 310-390-9018