=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811390040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UCLA RONALD REAGAN HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2014
-----------------------------------------------------
Last Update Date | 10/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12302 WILLOW SPRING DR
-----------------------------------------------------
City | MOORPARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93021-2780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-267-7610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 757 WESTWOOD PLAZA
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-267-7610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NP II
-----------------------------------------------------
Name | NORMA TIEDGE II
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 310-267-7610
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 95001281
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------