=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023378411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VERNON J KNUDSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2012
-----------------------------------------------------
Last Update Date | 05/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4324 W SLAUSON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90043-2808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-294-7153
-----------------------------------------------------
Fax | 323-294-7155
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4324 W SLAUSON AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90043-2808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-294-7153
-----------------------------------------------------
Fax | 323-294-7155
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VERNON J KNUDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-294-7153
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | PHY 19085
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------