Provider Demographics
NPI:1487667002
Name:CARL LAURYSSEN MD PROF CORP.
Entity Type:Organization
Organization Name:CARL LAURYSSEN MD PROF CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAURYSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-358-2490
Mailing Address - Street 1:8201 BEVERLY BLVD
Mailing Address - Street 2:SUITE 405
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8201 BEVERLY BLVD STE 405
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4505
Practice Address - Country:US
Practice Address - Phone:323-272-4678
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207T00000X
CAC50914261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19938Medicare PIN
CA5986390001Medicare NSC