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General NPI Number Information
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NPI Number | 1801895065
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Entity Type | Organization
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Legal Business Name | POM POM'S CASTLE
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Dates
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Enumeration Date | 07/19/2005
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Last Update Date | 08/14/2008
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Provider Practice Location Address
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Address Line | 971 E 43RD ST
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City | LOS ANGELES
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State | CA
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Zip | 90011-3040
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Country | US
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Telephone | 323-778-5433
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Fax | 323-232-7190
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Provider Business Mailing Address
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Address Line | PO BOX 470652
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City | LOS ANGELES
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State | CA
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Zip | 90047-9352
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Country | US
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Telephone | 323-232-7190
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Fax |
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Authorized Official
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Title or Position | EXECTIVE DIRECTOR
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Name | MRS. LORRAINE OLIVER
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Credential |
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Telephone | 323-778-5433
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 190329RN
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License Number State | CA
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