=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821640137
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | L SNYDER INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2019
-----------------------------------------------------
Last Update Date | 07/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34052 LA PLAZA #101
-----------------------------------------------------
City | DANA POINT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-496-4369
-----------------------------------------------------
Fax | 949-496-9365
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34145 PACIFIC COAST HIGHWAY #343
-----------------------------------------------------
City | DANA POINT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-616-4627
-----------------------------------------------------
Fax | 949-496-9365
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN -ADDICTION SPECIALIST
-----------------------------------------------------
Name | LARRY SNYDER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 949-616-4627
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------