=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689205049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALIFORNIA NEUROENDOVASCULAR SPECIALISTS MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2020
-----------------------------------------------------
Last Update Date | 02/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 N LAKE AVE STE 800
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-1857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-491-9270
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 530 S LAKE AVE # 439
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91101-3515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-522-5304
-----------------------------------------------------
Fax | 562-491-7985
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WLED WAZNI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 562-522-5304
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084A2900X
-----------------------------------------------------
Taxonomy Name | Neurocritical Care Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------