Provider Demographics
NPI:1104864131
Name:TORRANCE ORTHOPAEDIC AND SPORTS MEDICINE GROUP
Entity Type:Organization
Organization Name:TORRANCE ORTHOPAEDIC AND SPORTS MEDICINE GROUP
Other - Org Name:COASTALORTHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:A
Authorized Official - Last Name:AMEZOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-316-6190
Mailing Address - Street 1:5215 TORRANCE BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4009
Mailing Address - Country:US
Mailing Address - Phone:310-316-6190
Mailing Address - Fax:310-540-7362
Practice Address - Street 1:5215 TORRANCE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4009
Practice Address - Country:US
Practice Address - Phone:310-316-6190
Practice Address - Fax:310-540-7362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22653207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22653OtherFICTICIOUS NAME PERMIT
W20804Medicare PIN
CA22653OtherFICTICIOUS NAME PERMIT