=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972642577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONG BEACH SPRING FAMILY MEDICAL GRP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 06/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6510 E SPRING ST
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90815-1554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-421-4791
-----------------------------------------------------
Fax | 562-496-1180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6510 E SPRING ST
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90815-1554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-421-4791
-----------------------------------------------------
Fax | 562-496-1180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JARED LEIGH PIETY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 562-421-4791
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------