=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265170351
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT LUM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2022
-----------------------------------------------------
Last Update Date | 05/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1625 W OLYMPIC BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90015-3809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-632-0256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 467 SOLANO AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90012-1050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-318-4955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 302137
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------