=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790038883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RADIANCE ANESTHESIA GROUP INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2012
-----------------------------------------------------
Last Update Date | 08/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5170 SEPULVEDA BLVD SUITE 220
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403-1171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-565-9802
-----------------------------------------------------
Fax | 818-995-8703
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5170 SEPULVEDA BLVD SUITE 220
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403-1171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-565-9802
-----------------------------------------------------
Fax | 818-995-8703
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. DAVID LEE NICOLAS
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 818-565-9802
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------