MEDICARE: MR. ETHAN M KREISWIRTH MA, ATC

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	174400000X	Specialist

General Provider Information

NPI Number	:	1336249978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ETHAN M KREISWIRTH MA, ATC

Provider Business Mailing Address
First Line	:	5361 W 126TH ST
Second Line	:
City	:	HAWTHORNE
State	:	CA
Zip	:	90250-4128
Country	:	US
Telephone Number	:	310-243-3894
Fax Number	:

Provider Business Practice Location Address
First Line	:	CAL STATE DOMINGUEZ HLS
Second Line	:	1000 E. VICTORIA ST.
City	:	CARSON
State	:	CA
Zip	:	90747-0001
Country	:	US
Telephone Number	:	310-243-3894
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2006
Last Update Date	:	07/08/2007

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