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General NPI Number Information
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NPI Number | 1760664411
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Entity Type | Organization
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Legal Business Name | KEITH L AGRE, MD, MEDICAL CORPORATION
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Dates
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Enumeration Date | 12/04/2007
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Last Update Date | 12/04/2007
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Provider Practice Location Address
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Address Line | 1125 S BEVERLY DR SUITE 110
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City | LOS ANGELES
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State | CA
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Zip | 90035-1148
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Country | US
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Telephone | 310-276-2033
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Fax | 310-858-3857
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Provider Business Mailing Address
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Address Line | 1125 S BEVERLY DR SUITE 110
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City | LOS ANGELES
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State | CA
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Zip | 90035-1148
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Country | US
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Telephone | 310-276-2033
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Fax | 310-858-3857
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Authorized Official
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Title or Position | PRESIDENT
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Name | KEITH L AGRE
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Credential | M.D.
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Telephone | 310-276-2033
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | C24838
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License Number State | CA
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