=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043679368
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MULTICARE MEDICAL CENTER CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2016
-----------------------------------------------------
Last Update Date | 02/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 S PACIFIC AVE SUITE #201
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-2656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-570-6960
-----------------------------------------------------
Fax | 424-570-6952
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3129
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90510-3129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-792-3914
-----------------------------------------------------
Fax | 855-898-4055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BAO T NGUYEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 424-570-6960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------