=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508109877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ETHELRED E CARTER MEDICAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2013
-----------------------------------------------------
Last Update Date | 04/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1700 E CESAR E CHAVEZ AVE SUITE #3700
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90033-2424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-260-7252
-----------------------------------------------------
Fax | 323-260-7864
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1700 E CESAR E CHAVEZ AVE SUITE #3700
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90033-2424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-260-7252
-----------------------------------------------------
Fax | 323-260-7864
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE OWNER
-----------------------------------------------------
Name | ETHELRED E CARTER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-260-7252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | A29534
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------