Healthcare Provider Details

I. General information

NPI: 1104864131
Provider Name (Legal Business Name): TORRANCE ORTHOPAEDIC AND SPORTS MEDICINE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 TORRANCE BLVD STE 210
TORRANCE CA
90503-4009
US

IV. Provider business mailing address

5215 TORRANCE BLVD STE 210
TORRANCE CA
90503-4009
US

V. Phone/Fax

Practice location:
  • Phone: 310-316-6190
  • Fax: 310-540-7362
Mailing address:
  • Phone: 310-316-6190
  • Fax: 310-540-7362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number22653
License Number StateCA

VIII. Authorized Official

Name: DIANA A AMEZOLA
Title or Position: BILLING MANAGER
Credential:
Phone: 310-316-6190