=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720440258
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BC MEDICAL, A PROFESSIONAL MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2016
-----------------------------------------------------
Last Update Date | 03/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2438 MANHATTAN AVE
-----------------------------------------------------
City | HERMOSA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90254-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-333-0831
-----------------------------------------------------
Fax | 310-306-5555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2438 MANHATTAN AVE
-----------------------------------------------------
City | HERMOSA BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90254-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-333-0831
-----------------------------------------------------
Fax | 310-306-5555
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KATHRYN SHANNON MCMENAMAN
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 323-333-0831
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 20A13050
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------