=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902009988
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NETWAVE NEURODIAGNOSTICS AND PAIN MANAGEMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14507 HAWTHORNE BLVD
-----------------------------------------------------
City | LAWNDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90260-1520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-856-2685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14507 HAWTHORNE BLVD
-----------------------------------------------------
City | LAWNDALE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90260-1520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL ALLEN COBURN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-856-2685
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------