Basic Information
| Provider Information | |||||||||
| NPI: | 1538331848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREGG SMALL MEDICAL CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15720 VENTURA BLVD | ||||||||
| Address2: | SUITE 227 | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362914 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 15720 VENTURA BLVD | ||||||||
| Address2: | SUITE 227 | ||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189077828 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2008 | ||||||||
| LastUpdateDate: | 04/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | SMALL | ||||||||
| AuthorizedOfficialFirstName: | GREGG | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8189077828 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | G70119 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.