=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831238492
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALT JAY MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1930 WILSHIRE BLVD SUITE 505
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90057-3605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-483-9902
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2011 PRAY ST
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92833-5070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-803-0468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER'S ASSISTANT
-----------------------------------------------------
Name | SHERINE GANEGODA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 213-483-9902
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | G00078400
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------