=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154956100
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINAL STENOSIS AND DISC CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2020
-----------------------------------------------------
Last Update Date | 03/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2428 SANTA MONICA BLVD # 305
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-2045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-451-5851
-----------------------------------------------------
Fax | 310-458-0051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2428 SANTA MONICA BLVD # 305
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-2045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-451-5851
-----------------------------------------------------
Fax | 310-458-0051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. PETER LE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 310-451-5851
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------