Basic Information
| Provider Information | |||||||||
| NPI: | 1083740740 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIATT | ||||||||
| FirstName: | TED | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1339 20TH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108298945 | ||||||||
| FaxNumber: | 3108298455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1339 20TH ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108298945 | ||||||||
| FaxNumber: | 3108298455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1473 | 01 | CA | BEHAVIORAL HEALTH AND SOC | OTHER |