Basic Information
| Provider Information | |||||||||
| NPI: | 1205252673 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANTA MONICA SPORTS MEDICINE INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 WILSHIRE BLVD STE 410 | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904011886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104581259 | ||||||||
| FaxNumber: | 3104581395 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 WILSHIRE BLVD. #410 | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104581259 | ||||||||
| FaxNumber: | 3104581395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2014 | ||||||||
| LastUpdateDate: | 03/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | MORAN | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3104581259 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | A63662 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.