=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134563638
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI STAR ORTHOPAEDICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2013
-----------------------------------------------------
Last Update Date | 04/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5220 CLARK AVE 100
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90712-2618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-297-0828
-----------------------------------------------------
Fax | 562-866-6818
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5220 CLARK AVE 100
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90712-2618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-297-0828
-----------------------------------------------------
Fax | 562-866-6818
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | CHRISTOPHER ARMSTRONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 562-297-0828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | G85430
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------