Healthcare Provider Details

I. General information

NPI: 1437240355
Provider Name (Legal Business Name): RICHARD J. SPELTS JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 05/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6815 NOBLE AVE
VAN NUYS CA
91405-3796
US

IV. Provider business mailing address

6815 NOBLE AVE
VAN NUYS CA
91405-3796
US

V. Phone/Fax

Practice location:
  • Phone: 818-901-6600
  • Fax: 818-997-7826
Mailing address:
  • Phone: 818-901-6600
  • Fax: 818-997-7826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A8491
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: