MEDICARE: HYDRA HEALTH CENTERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A73853	CA

General Provider Information

NPI Number	:	1316335334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HYDRA HEALTH CENTERS

Provider Business Mailing Address
First Line	:	15332 ANTIOCH ST
Second Line	:	SUITE: 820
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272-3628
Country	:	US
Telephone Number	:	818-749-4778
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 CONTINENTAL BLVD
Second Line	:	STE 600
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-5076
Country	:	US
Telephone Number	:	818-749-4778
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FREDERICK BUTLER II
Credential	:	MD
Telephone Number	:	818-749-4778

Provider Enumeration Date	:	12/29/2014
Last Update Date	:	12/29/2014

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