=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093959900
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRANIOFACIAL/CLEFT PALATE PROGRAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2009
-----------------------------------------------------
Last Update Date | 08/18/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 W ADAMS BLVD 4TH FLOOR
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90007-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-742-1433
-----------------------------------------------------
Fax | 213-742-1496
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 W ADAMS BLVD 4TH FLOOR
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90007-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-742-1433
-----------------------------------------------------
Fax | 213-742-1496
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PLASTIC SURGEON
-----------------------------------------------------
Name | DR. LIBBY F WILSON
-----------------------------------------------------
Credential | M.D.,
-----------------------------------------------------
Telephone | 213-742-1433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------