=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144608597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY HEALTH MEDICAL ASSOCIATES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2015
-----------------------------------------------------
Last Update Date | 06/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 S MOORPARK RD
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91361-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-278-0804
-----------------------------------------------------
Fax | 650-618-1461
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1710 N MOORPARK RD SUITE NUMBER 220
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360-5133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-278-0804
-----------------------------------------------------
Fax | 650-618-1461
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL EDWARD EIFFERT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 650-278-0804
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | A79039
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A79039
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------