Provider Demographics
NPI:1497968382
Name:LAWRENCE W KNEISLEY, M.D., INC.
Entity Type:Organization
Organization Name:LAWRENCE W KNEISLEY, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:W,
Authorized Official - Last Name:KNEISLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-530-8822
Mailing Address - Street 1:23560 MADISON STREET
Mailing Address - Street 2:#205
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505
Mailing Address - Country:US
Mailing Address - Phone:310-530-8822
Mailing Address - Fax:310-530-0288
Practice Address - Street 1:23560 MADISON ST
Practice Address - Street 2:#205
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4708
Practice Address - Country:US
Practice Address - Phone:310-530-8822
Practice Address - Fax:310-530-0288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28290174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA43681Medicare UPIN
CAG28290Medicare PIN