Basic Information
| Provider Information | |||||||||
| NPI: | 1801142963 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AEGIS MEDICAL SYSTEMS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14240 IMPERIAL HWY | ||||||||
| Address2: | |||||||||
| City: | LA MIRADA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906381940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629461587 | ||||||||
| FaxNumber: | 5629465740 | ||||||||
| Practice Location | |||||||||
| Address1: | 7256 REMMET AVE | ||||||||
| Address2: | |||||||||
| City: | CANOGA PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182060360 | ||||||||
| FaxNumber: | 8182060370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2012 | ||||||||
| LastUpdateDate: | 07/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | JOO YOUNG | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 5629461587 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | M.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 19-053 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 19-053 | 01 | CA | NTP | OTHER |