=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861892226
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DECIO RANGEL, M.D., A PROFESSIONAL MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2014
-----------------------------------------------------
Last Update Date | 09/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 SANTA MONICA BLVD STE 470W
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-2181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-828-7454
-----------------------------------------------------
Fax | 310-828-6362
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 SANTA MONICA BLVD STE 470W
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90404-2181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-828-7454
-----------------------------------------------------
Fax | 310-828-6362
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DECIO RANGEL
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-828-7454
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | A25197
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------