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General NPI Number Information
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NPI Number | 1376711440
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Entity Type | Organization
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Legal Business Name | VENICE CULVER MARINA MEDICAL GROUP INC
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Dates
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Enumeration Date | 02/12/2008
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Last Update Date | 10/10/2017
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Provider Practice Location Address
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Address Line | 12212 W WASHINGTON BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90066
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Country | US
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Telephone | 310-391-5241
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Fax | 310-397-4324
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Provider Business Mailing Address
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Address Line | PO BOX 24706
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City | LOS ANGELES
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State | CA
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Zip | 90024
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Country | US
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Telephone | 310-391-5241
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Fax | 310-397-4324
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | MR. JAY TEHRANI
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Credential | BILLING MANAGER
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Telephone | 310-672-9000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | A32561
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License Number State | CA
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