Basic Information
| Provider Information | |||||||||
| NPI: | 1023401585 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOS ANGELES SHOULDER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2351 OCEAN VIEW DR | ||||||||
| Address2: | |||||||||
| City: | SIGNAL HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907553778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105463461 | ||||||||
| FaxNumber: | 3107988231 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S SEPULVEDA BLVD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | MANHATTAN BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902666814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105463461 | ||||||||
| FaxNumber: | 3107988231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2015 | ||||||||
| LastUpdateDate: | 03/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | HARTSHORN | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | AUGUST | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3105463461 | ||||||||
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| 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 | 207X00000X | A107628 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.