Provider Demographics
NPI:1437779642
Name:ORIGINAL BREATH
Entity Type:Organization
Organization Name:ORIGINAL BREATH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURTON
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM
Authorized Official - Phone:310-980-9764
Mailing Address - Street 1:1106 N LA CIENEGA BLVD STE 206
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90069-2493
Mailing Address - Country:US
Mailing Address - Phone:310-980-9764
Mailing Address - Fax:
Practice Address - Street 1:1106 N LA CIENEGA BLVD STE 203
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90069-2493
Practice Address - Country:US
Practice Address - Phone:310-659-8500
Practice Address - Fax:310-504-3171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-17
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A8154OtherOSTEOPATHIC PHYSICIAN AND SURGEON