Provider Demographics
NPI:1033303920
Name:SAN ANTONIO LENNOX
Entity Type:Organization
Organization Name:SAN ANTONIO LENNOX
Other - Org Name:MANUEL ACEVEDO
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:ERNESTO
Authorized Official - Last Name:ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-673-1922
Mailing Address - Street 1:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90251-1045
Mailing Address - Country:US
Mailing Address - Phone:310-679-1922
Mailing Address - Fax:310-673-7701
Practice Address - Street 1:10811 S GREVILLEA AVE
Practice Address - Street 2:
Practice Address - City:LENNOX
Practice Address - State:CA
Practice Address - Zip Code:90304-2325
Practice Address - Country:US
Practice Address - Phone:310-673-1922
Practice Address - Fax:310-673-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74961208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1336251032OtherNPI
CA1336251032OtherNPI