MEDICARE: DR. KRYSTAL M. NEELY MD

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	208000000X	Pediatrics Physician	A69107	CA

General Provider Information

NPI Number	:	1588704365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRYSTAL M. NEELY MD

Provider Business Mailing Address
First Line	:	PO BOX 4636
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90231-4636
Country	:	US
Telephone Number	:	310-701-9766
Fax Number	:	310-763-2315

Provider Business Practice Location Address
First Line	:	403 S LONG BEACH BLVD
Second Line	:	SUITE B
City	:	COMPTON
State	:	CA
Zip	:	90221-3449
Country	:	US
Telephone Number	:	323-774-6551
Fax Number	:	310-763-2315

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

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	07/08/2007

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