MEDICARE: MEDICAL SUPPORT LOS ANGELES A 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	202C00000X	Independent Medical Examiner Physician

General Provider Information

NPI Number	:	1790227189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL SUPPORT LOS ANGELES A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	1294 E COLORADO BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91106-1901
Country	:	US
Telephone Number	:	626-407-2152
Fax Number	:	626-239-3666

Provider Business Practice Location Address
First Line	:	12626 RIVERSIDE DR
Second Line	:	SUITE #511
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91607-3420
Country	:	US
Telephone Number	:	818-508-1417
Fax Number	:	818-508-1458

Authorized Official
Title or Position	:	CFO
Name	:	SAHNIAH SICIARZ-LAMBER
Credential	:
Telephone Number	:	626-407-2152

Provider Enumeration Date	:	11/16/2016
Last Update Date	:	11/16/2016

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