Basic Information
| Provider Information | |||||||||
| NPI: | 1417086323 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OWENS | ||||||||
| FirstName: | ARTHUR | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 16932 S BERENDO AVE | ||||||||
| Address2: | APT # C | ||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902475579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628653644 | ||||||||
| FaxNumber: | 5628655244 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 HAMPTON DR | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902912623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103096001 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 07/03/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.