Basic Information
| Provider Information | |||||||||
| NPI: | 1184773202 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIRACLE MILE MEDICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17358 | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914167358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239301040 | ||||||||
| FaxNumber: | 3239370525 | ||||||||
| Practice Location | |||||||||
| Address1: | 6000 SAN VICENTE BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900364404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3239301040 | ||||||||
| FaxNumber: | 3239370525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | THEIRING | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3235563942 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 930000143 | CA | Y | Hospitals | General Acute Care Hospital |
No ID Information.