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NPI Code Detail

MEDICARE: EDILITA DE BODA PAC

MEDICARE: EDILITA DE BODA PAC
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
1363AM0700XMedical Physician AssistantPA 15259CA

General Provider Information

NPI Number : 1982892956
Entity Type Code : Individual
Provider Name (Legal Business Name) : EDILITA DE BODA PAC
Provider Business Mailing Address
First Line : 1535 LOMITA BLVD
Second Line :
City : HARBOR CITY
State : CA
Zip : 90710-2024
Country : US
Telephone Number : 310-530-9300
Fax Number :
Provider Business Practice Location Address
First Line : 1535 LOMITA BLVD
Second Line :
City : HARBOR CITY
State : CA
Zip : 90710-2024
Country : US
Telephone Number : 310-530-9300
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/04/2007
Last Update Date : 05/06/2008

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Directions to “ EDILITA DE BODA PAC” Practice Location

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