=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528429636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLOW MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2016
-----------------------------------------------------
Last Update Date | 03/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20315 VENTURA BLVD SUITE A
-----------------------------------------------------
City | WOODLAND HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91364-2449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-658-3830
-----------------------------------------------------
Fax | 888-837-4246
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20315 VENTURA BLVD SUITE A
-----------------------------------------------------
City | WOODLAND HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91364-2449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-658-3830
-----------------------------------------------------
Fax | 888-837-4246
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/ PHYSICIAN/OWNER
-----------------------------------------------------
Name | DR. MICHAEL ROBIN LEWIS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 818-658-3830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | A103852
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------