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General NPI Number Information
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NPI Number | 1871738971
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Entity Type | Organization
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Legal Business Name | EYE CARE FOR DIABETICS MEDICAL GROUP, INC
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Dates
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Enumeration Date | 12/04/2008
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Last Update Date | 12/04/2008
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Provider Practice Location Address
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Address Line | 323 N PRAIRIE AVE SUITE 217
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City | INGLEWOOD
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State | CA
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Zip | 90301-4502
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Country | US
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Telephone | 310-671-0909
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Fax | 310-412-0066
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Provider Business Mailing Address
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Address Line | 323 N PRAIRIE AVE SUITE 217
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City | INGLEWOOD
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State | CA
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Zip | 90301-4502
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Country | US
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Telephone | 310-671-0909
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Fax | 310-412-0066
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | MR. LEROY W VAUGHN SR.
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Credential | MD
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Telephone | 310-671-0909
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | A30576
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License Number State | CA
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