=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245653617
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL W HANSEN OD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2014
-----------------------------------------------------
Last Update Date | 01/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 AVENUE I
-----------------------------------------------------
City | REDONDO BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90277-5601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-373-3191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 ROSECRANS AVE STE 1215
-----------------------------------------------------
City | EL SEGUNDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90245-4749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-321-6990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL HANSEN
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 310-321-6990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT11354TPL
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------