Healthcare Provider Details

I. General information

NPI: 1811936743
Provider Name (Legal Business Name): SPORTS AND SPINE ORTHOPAEDICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23456 HAWTHORNE BLVD SUITE 200 BUILDING 5
TORRANCE CA
90505-4716
US

IV. Provider business mailing address

23456 HAWTHORNE BLVD SUITE 200 BUILDING 5
TORRANCE CA
90505-4716
US

V. Phone/Fax

Practice location:
  • Phone: 310-375-8700
  • Fax:
Mailing address:
  • Phone: 310-375-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA62201
License Number StateCA

VIII. Authorized Official

Name: MRS. NORA MIES
Title or Position: PATIENT ACCOUNT REP
Credential:
Phone: 310-375-8700