=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104154970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TENGIS RIZNIS, MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2009
-----------------------------------------------------
Last Update Date | 12/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4443 SPECTRUM
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-219-1311
-----------------------------------------------------
Fax | 949-812-7602
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4443 SPECTRUM
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-219-1311
-----------------------------------------------------
Fax | 949-812-7602
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TENGIS RIZNIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 949-716-0011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A86212
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------