=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295223345
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCLA COMPREHENSIVE SURGICAL MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2018
-----------------------------------------------------
Last Update Date | 05/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3628 E IMPERIAL HWY STE 204
-----------------------------------------------------
City | LYNWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-808-9797
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3628 E IMPERIAL HWY STE 204
-----------------------------------------------------
City | LYNWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90262-2643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-213-4290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MAXINE ANDERSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 424-213-4290
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------