=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336964121
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMNIOTIC WOUND CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2024
-----------------------------------------------------
Last Update Date | 11/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12100 WILSHIRE BLVD STE 800
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90025-7140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-692-4692
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13563 EGBERT ST
-----------------------------------------------------
City | SYLMAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91342-1846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-723-1584
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | GHASSAN SYED
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-692-4692
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------