MEDICARE: NTA MEDICAL CORPORATION

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	G749521	CA

General Provider Information

NPI Number	:	1558324947
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NTA MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	2815 W SUNSET BLVD
Second Line	:	SUITE #108
City	:	LOS ANGELES
State	:	CA
Zip	:	90026-2167
Country	:	US
Telephone Number	:	213-484-6995
Fax Number	:

Provider Business Practice Location Address
First Line	:	2815 W SUNSET BLVD
Second Line	:	SUITE #108
City	:	LOS ANGELES
State	:	CA
Zip	:	90026-2167
Country	:	US
Telephone Number	:	213-484-6995
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. TONY KILEY
Credential	:	MD
Telephone Number	:	213-484-6995

Provider Enumeration Date	:	04/08/2006
Last Update Date	:	08/22/2020

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