Provider Demographics
NPI:1093305260
Name:RILLIE MEDICAL GROUP
Entity Type:Organization
Organization Name:RILLIE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-896-5183
Mailing Address - Street 1:1221 N ORANGE DR
Mailing Address - Street 2:STE 317
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038
Mailing Address - Country:US
Mailing Address - Phone:310-896-5183
Mailing Address - Fax:
Practice Address - Street 1:1221 N ORANGE DR
Practice Address - Street 2:STE 317
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038
Practice Address - Country:US
Practice Address - Phone:310-896-5183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C50677OtherCALIFORNIA MEDICAL LICENSE