=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679993406
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEIA RISPOLI M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2014
-----------------------------------------------------
Last Update Date | 06/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4551 GLENCOE AVE STE 145
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292-6385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-405-0595
-----------------------------------------------------
Fax | 310-997-2766
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3129
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90510-3129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-792-3914
-----------------------------------------------------
Fax | 855-898-4055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | A160496
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208VP0014X
-----------------------------------------------------
Taxonomy Name | Interventional Pain Medicine Physician
-----------------------------------------------------
License Number | A160496
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------