| NPI | 1699923235 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MEDARDO C SUPNET Owner 310-605-4260 |
| Organization Subpart ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: CA A46203) |
| Additional Taxonomies | 174400000X Specialist (Licence: CA A50125) |
| 363AM0700X Physician Assistant, Medical (Licence: CA PA16910) | |
| Enumeration Date | 2008-09-08 |
| Last Update Date | 2008-09-08 |