=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861895401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SMILE PEDIATRIC THERAPY AND DIAGNOSTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2014
-----------------------------------------------------
Last Update Date | 09/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5000 W SUNSET BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90027-5861
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-644-9380
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11854 BEVERLY DR
-----------------------------------------------------
City | WHITTIER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90601-2737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-652-1593
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | MADELEINE JAY HAAS
-----------------------------------------------------
Credential | M.S., OTR/L
-----------------------------------------------------
Telephone | 562-652-1593
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number | 14597
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------