=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154757201
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOW T PHYSICIANS OF CALIFORNIA PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2013
-----------------------------------------------------
Last Update Date | 09/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4968 BOOTH CIRCLE SUITE 110
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92604-3371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-544-5698
-----------------------------------------------------
Fax | 817-576-5699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 JOHN MCCAIN RD
-----------------------------------------------------
City | COLLEYVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76034-7302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-576-5698
-----------------------------------------------------
Fax | 817-576-5699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NATIONAL MEDICAL DIRECTOR
-----------------------------------------------------
Name | WILLIAM G REILLY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 877-544-5698
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------