=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154649481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN CALIFORNIA INJURY TREATMENT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2010
-----------------------------------------------------
Last Update Date | 05/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14365 PIPELINE AVE
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-5642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-364-8111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14365 PIPELINE AVE
-----------------------------------------------------
City | CHINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91710-5642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-364-8111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COLLECTOR / BILLER
-----------------------------------------------------
Name | LAURA ELIZARRARAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 626-275-4544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NX0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Chiropractor
-----------------------------------------------------
License Number | G41089
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------