Provider Demographics
NPI:1164797825
Name:SMILE PEDIATRIC THERAPY AND DIAGNOSTICS
Entity Type:Organization
Organization Name:SMILE PEDIATRIC THERAPY AND DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAJJAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-644-9380
Mailing Address - Street 1:5000 W SUNSET BLVD STE 510
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5864
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5000 W SUNSET BLVD STE 510
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5864
Practice Address - Country:US
Practice Address - Phone:323-644-9380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities