Basic Information
| Provider Information | |||||||||
| NPI: | 1376752584 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST LOS ANGELES VA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14010 CAPTAINS ROW APT 137 | ||||||||
| Address2: | |||||||||
| City: | MARINA DEL REY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902927367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108237848 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11301 WILSHIRE BLVD # 117 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900731003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104783711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCHULTZ | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | RESIDENT PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3104783711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | A94442 | CA | Y | Hospitals | Rehabilitation Hospital |
No ID Information.