=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447454814
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PEDRO OLMEDOCOLOR PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 E SOUTH ST SUITE 305
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90805-4549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-622-8102
-----------------------------------------------------
Fax | 562-622-6072
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 E SOUTH ST SUITE 305
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90805-4549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-622-8102
-----------------------------------------------------
Fax | 562-622-6072
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA 19056
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------