Healthcare Provider Details

I. General information

NPI: 1154780559
Provider Name (Legal Business Name): ID MED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23430 HAWTHORNE BLVD STE 200
TORRANCE CA
90505-4730
US

IV. Provider business mailing address

23430 HAWTHORNE BLVD STE 200
TORRANCE CA
90505-4730
US

V. Phone/Fax

Practice location:
  • Phone: 310-784-5880
  • Fax: 310-325-3117
Mailing address:
  • Phone: 310-784-5880
  • Fax: 310-325-3117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberA118780
License Number StateCA

VIII. Authorized Official

Name: ELIZABETH LUBLINER
Title or Position: ADMINISTRATOR
Credential:
Phone: 310-784-5880