Healthcare Provider Details

I. General information

NPI: 1750683306
Provider Name (Legal Business Name): DECIO M RANGEL MD, A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD STE 470W
SANTA MONICA CA
90404-2192
US

IV. Provider business mailing address

2001 SANTA MONICA BLVD STE 470W
SANTA MONICA CA
90404-2192
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-7454
  • Fax: 310-828-6362
Mailing address:
  • Phone: 310-828-7454
  • Fax: 310-828-6362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA25197
License Number StateCA

VIII. Authorized Official

Name: DR. DECIO M RANGEL
Title or Position: OWNER
Credential: MD
Phone: 310-828-7454