=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538474655
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AFTERGLOW DIAGNOSTICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2010
-----------------------------------------------------
Last Update Date | 08/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 ROSECRANS AVE BLDG 7, 4TH FLOOR
-----------------------------------------------------
City | MANHATTAN BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90266-3708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-321-7818
-----------------------------------------------------
Fax | 310-667-8818
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 ROSECRANS AVE BLDG 7, 4TH FLOOR
-----------------------------------------------------
City | MANHATTAN BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90266-3708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-321-7818
-----------------------------------------------------
Fax | 310-667-8818
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. LIZA MARIE VISMANOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-321-7818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------