Provider Demographics
NPI:1164682035
Name:CHILDREN'S HOSPITAL LOS ANGELES
Entity Type:Organization
Organization Name:CHILDREN'S HOSPITAL LOS ANGELES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR.VP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:LIEBERENZ
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:323-361-2235
Mailing Address - Street 1:4650 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6062
Mailing Address - Country:US
Mailing Address - Phone:323-361-2519
Mailing Address - Fax:
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-2519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDRENS HOSPITAL OF LOS ANGELES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-13
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000032261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA052321Medicare Oscar/Certification