Basic Information
| Provider Information | |||||||||
| NPI: | 1952496572 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VA GREATER LOS ANGELES MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12122 EXCELSIOR DRIVE | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628636315 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11301 WILSHIRE BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104783711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | EISNER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | WALLACE | ||||||||
| AuthorizedOfficialTitleorPosition: | KINESIOTHERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 3104783711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | RKT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | 1031 | CA | Y | Hospitals | Rehabilitation Hospital |
No ID Information.