=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205252665
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILE PEDIATRIC THERAPY & DIAGNOSTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2014
-----------------------------------------------------
Last Update Date | 03/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5000 W SUNSET BLVD STE 510
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90027-5864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-644-9380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5000 W SUNSET BLVD STE 510
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90027-5864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CLINICAL SERVICES
-----------------------------------------------------
Name | MRS. NICOLE HAJJAR
-----------------------------------------------------
Credential | MS, CCC-SLP
-----------------------------------------------------
Telephone | 323-644-9380
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number | RPE 8845
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------