MEDICARE: VETERANS AFFAIRS HEALTHCARE SYSTEM

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	286500000X	Military Hospital	1672	CA

General Provider Information

NPI Number	:	1871686550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VETERANS AFFAIRS HEALTHCARE SYSTEM

Provider Business Mailing Address
First Line	:	8839 ORCHARD AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90044
Country	:	US
Telephone Number	:	323-971-1338
Fax Number	:

Provider Business Practice Location Address
First Line	:	11301 WILSHIRE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90073
Country	:	US
Telephone Number	:	310-478-3711
Fax Number	:

Authorized Official
Title or Position	:	REGISTERED KINESIOTHERAPIST
Name	:	MS. CHANDA NICOLE SIMON
Credential	:	MHA, RKT
Telephone Number	:	323-478-3711

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	08/22/2020

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Practice Location Address:

11301 WILSHIRE BLVD , BLDG 500
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1962789230 — VA GREATER LOS ANGELES NUCLEAR MEDICINE DEPARTMENT
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1609243534 — U.S. DEPARTMENT OF VETERAN'S AFFAIRS
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1891648754 — STEPHANIE DOMINGUEZ DE VERA
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