MEDICARE: ANGELS BASEBALL LP

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	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1497188742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGELS BASEBALL LP

Provider Business Mailing Address
First Line	:	2000 GENE AUTRY WAY
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92806
Country	:	US
Telephone Number	:	714-940-2093
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 GENE AUTRY WAY
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92806
Country	:	US
Telephone Number	:	714-940-2093
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	CRAIG MILHOUSE
Credential	:	MD
Telephone Number	:	714-940-2093

Provider Enumeration Date	:	08/09/2013
Last Update Date	:	08/09/2013

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