=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578116877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LA NEURO MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2019
-----------------------------------------------------
Last Update Date | 07/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11843 DOROTHY ST APT 2
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049-4456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-245-5884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11843 DOROTHY ST APT 2
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049-4456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-883-4624
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | OCTAVIO CALDERON
-----------------------------------------------------
Credential | CNIM
-----------------------------------------------------
Telephone | 310-883-4624
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------