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General NPI Number Information
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NPI Number | 1386009041
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Entity Type | Organization
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Legal Business Name | KPG ASTORIA, LLC
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Dates
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Enumeration Date | 12/23/2015
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Last Update Date | 12/23/2015
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Provider Practice Location Address
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Address Line | 9000 W SUNSET BLVD STE 1500
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City | WEST HOLLYWOOD
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State | CA
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Zip | 90069-5815
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Country | US
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Telephone | 310-975-1450
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Fax |
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Provider Business Mailing Address
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Address Line | 9000 W SUNSET BLVD STE 1500
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City | WEST HOLLYWOOD
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State | CA
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Zip | 90069-5815
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIEF OPERATIONS OFFICER
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Name | DARRYL OLIVIER
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Credential |
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Telephone | 310-975-1450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RA0401X
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Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
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License Number | MD168198
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License Number State | OR
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