=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053930248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHINE MMG INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2020
-----------------------------------------------------
Last Update Date | 04/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 N BRAND BLVD STE 625A
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91203-2347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-745-0070
-----------------------------------------------------
Fax | 818-745-0065
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 N BRAND BLVD STE 625A
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91203-2347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-745-0070
-----------------------------------------------------
Fax | 818-745-0065
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | EMIL GOLUB
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 424-204-6004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------