=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457769002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLLYWOOD HEALTH PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2014
-----------------------------------------------------
Last Update Date | 07/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1710 N MCCADDEN PL
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90028-4603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-350-2276
-----------------------------------------------------
Fax | 323-461-1995
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1710 N MCCADDEN PL
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90028-4603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-350-2276
-----------------------------------------------------
Fax | 323-461-1995
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ANDREA LAWENT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-350-2276
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 20035
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------