=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205245495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BSTMD, INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2014
-----------------------------------------------------
Last Update Date | 08/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3585 MAPLE ST SUITE # 205
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93003-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-654-0926
-----------------------------------------------------
Fax | 805-654-0949
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3585 MAPLE ST SUITE # 205
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93003-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-654-0926
-----------------------------------------------------
Fax | 805-654-0949
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | BRIAN S TAYLOR
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 805-654-0926
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | G75540
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------