=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225434343
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXPER-TECH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2014
-----------------------------------------------------
Last Update Date | 03/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1437 ARMACOST AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-705-5003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 913 LINDENCLIFF ST
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90502-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-705-5003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, SONOGRAPHER
-----------------------------------------------------
Name | MR. GREGG STUART NIELSON
-----------------------------------------------------
Credential | RVT
-----------------------------------------------------
Telephone | 805-705-5003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 154435
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------