MEDICARE: LEIA RISPOLI M.D.

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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	A160496	CA
2	208VP0014X	Interventional Pain Medicine Physician	A160496	CA

General Provider Information

NPI Number	:	1679993406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEIA RISPOLI M.D.

Provider Business Mailing Address
First Line	:	PO BOX 3129
Second Line	:
City	:	TORRANCE
State	:	CA
Zip	:	90510-3129
Country	:	US
Telephone Number	:	310-792-3914
Fax Number	:	855-898-4055

Provider Business Practice Location Address
First Line	:	4551 GLENCOE AVE STE 145
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-6385
Country	:	US
Telephone Number	:	310-405-0595
Fax Number	:	310-997-2766

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

Provider Enumeration Date	:	04/19/2014
Last Update Date	:	06/09/2023

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