Basic Information
Provider Information
NPI: 1003139569
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WEAVER
FirstName: AARON
MiddleName: KANE
NamePrefix: MR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1725 MAIN ST
Address2:  
City: SANTA MONICA
State: CA
PostalCode: 904013289
CountryCode: US
TelephoneNumber: 3102603576
FaxNumber:  
Practice Location
Address1: 1725 MAIN ST
Address2:  
City: SANT MONICA
State: CA
PostalCode: 904013289
CountryCode: US
TelephoneNumber: 3102503576
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/11/2010
LastUpdateDate: 03/11/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171M00000X  Y Other Service ProvidersCase Manager/Care Coordinator 

No ID Information.


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