=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639357114
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACOSTA MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2008
-----------------------------------------------------
Last Update Date | 08/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 W EULALIA ST STE. 201
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91204-2849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-240-0601
-----------------------------------------------------
Fax | 818-240-0687
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 W EULALIA ST STE. 201
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91204-2849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-240-0601
-----------------------------------------------------
Fax | 818-240-0687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MALENA A WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 818-240-0601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G72214
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------