=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841408424
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL NEUROLOGICAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2007
-----------------------------------------------------
Last Update Date | 10/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6221 WILSHIRE BLVD SUITE 509
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90048-5201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-939-1689
-----------------------------------------------------
Fax | 323-939-7084
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3831 HUGHES AVE SUITE 506
-----------------------------------------------------
City | CULVER CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90232-2751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-939-1689
-----------------------------------------------------
Fax | 323-939-7084
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | BENJAMIN GROSS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 323-939-1689
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207T00000X
-----------------------------------------------------
Taxonomy Name | Neurological Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------