=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275712341
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMA PAIN THERAPY GROUP, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2007
-----------------------------------------------------
Last Update Date | 05/05/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 SHATTO PL # 200
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-1754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-736-0450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 SHATTO PL # 200
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-1754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-736-0450
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARTIN ANDRADE
-----------------------------------------------------
Credential | P.T
-----------------------------------------------------
Telephone | 213-736-0450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------