=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851446132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ADOLESCENT AND CHILDREN'S ORTHOPEDIC SURGEONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5353 BALBOA BLVD SUITE 202
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-789-9449
-----------------------------------------------------
Fax | 818-789-9339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5353 BALBOA BLVD SUITE 202
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91316-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-789-9449
-----------------------------------------------------
Fax | 818-789-9339
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. KEITH RICHARD BROOKENTHAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 818-789-9449
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XP3100X
-----------------------------------------------------
Taxonomy Name | Pediatric Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | A79821
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------