Healthcare Provider Details

I. General information

NPI: 1073734778
Provider Name (Legal Business Name): GLEN I KOMATSU M D A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 09/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 TORRANCE BLVD PALLIATIVE CARE
TORRANCE CA
90503-4607
US

IV. Provider business mailing address

6069 WOODFERN DR
RANCHO PALOS VERDES CA
90275-2263
US

V. Phone/Fax

Practice location:
  • Phone: 310-303-6840
  • Fax: 310-303-5574
Mailing address:
  • Phone: 310-545-9713
  • Fax: 310-546-1648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: GLEN I KOMATSU
Title or Position: OWNER
Credential: MD
Phone: 310-375-4585