=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376840793
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN DIEGO ANESTHESIA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2011
-----------------------------------------------------
Last Update Date | 02/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3434 MIDWAY DR STE 1008
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92110-4924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-273-8885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8721 SANTA MONICA BLVD # 222
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-4507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-273-8885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. ARA SALAZAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-273-8885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 173000000X
-----------------------------------------------------
Taxonomy Name | Legal Medicine
-----------------------------------------------------
License Number | A84519
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------