Basic Information
| Provider Information | |||||||||
| NPI: | 1356836993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALIFORNIA ORTHOPEDICS & SPINE INC | ||||||||
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| OtherOrganizationName: | MT. TAM ORTHOPEDICS, A MEDICAL CENTER, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 BON AIR RD | ||||||||
| Address2: | |||||||||
| City: | LARKSPUR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949391123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159275300 | ||||||||
| FaxNumber: | 4159276860 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 BON AIR RD STE 129 | ||||||||
| Address2: | |||||||||
| City: | LARKSPUR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949391139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159248900 | ||||||||
| FaxNumber: | 4159247149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2018 | ||||||||
| LastUpdateDate: | 10/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | OECHSEL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4159275300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CALIFORNIA ORTHO AND SPINE | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.