=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174061279
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROMOJ,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2017
-----------------------------------------------------
Last Update Date | 02/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1254 W 8TH ST APT 2
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-2944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-477-5360
-----------------------------------------------------
Fax | 424-477-5167
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1254 W 8TH ST APT 2
-----------------------------------------------------
City | SAN PEDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90731-2944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-477-5360
-----------------------------------------------------
Fax | 424-477-5167
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. PROMOJ SINGH LAKRA
-----------------------------------------------------
Credential | RCP
-----------------------------------------------------
Telephone | 424-477-5360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC2000X
-----------------------------------------------------
Taxonomy Name | Children's Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------