=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558496182
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT J STAHL & AMY J CALDER, ODS - A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 04/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1142 W REDONDO BEACH BLVD
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90247-3538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-323-5095
-----------------------------------------------------
Fax | 310-323-6046
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1142 W REDONDO BEACH BLVD
-----------------------------------------------------
City | GARDENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90247-3538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-323-5095
-----------------------------------------------------
Fax | 310-323-6046
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROBERT J. STAHL
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 310-323-5095
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 9599T
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------