=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902130057
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | URBAN FIT & THERAPY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2009
-----------------------------------------------------
Last Update Date | 09/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 W 11TH ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90015-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-994-1205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10501 WILSHIRE BLVD SUITE 1204
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90024-6302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-994-1205
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. RYAN PENDON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 310-994-1205
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | DC30452
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------