=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972996262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEVO GAS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2015
-----------------------------------------------------
Last Update Date | 05/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1210 TELLEM DR
-----------------------------------------------------
City | PACIFIC PALISADES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90272-2246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-732-6468
-----------------------------------------------------
Fax | 888-732-6468
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1210 TELLEM DR
-----------------------------------------------------
City | PACIFIC PALISADES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90272-2246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-732-6468
-----------------------------------------------------
Fax | 888-732-6468
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | AMIR MANSOOR KHAZAIELINAJAFABADI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 888-732-6468
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | A85856
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------