Provider Demographics
NPI:1568501120
Name:WALT JAY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:WALT JAY MEDICAL CORPORATION
Other - Org Name:INTEGRATIVE INDUSTRIAL AND FAMILY PRACTICE MEDICAL CLINICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER'S ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GANEGODA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-483-9902
Mailing Address - Street 1:318 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-2387
Mailing Address - Country:US
Mailing Address - Phone:626-943-7848
Mailing Address - Fax:
Practice Address - Street 1:1930 WILSHIRE BLVD
Practice Address - Street 2:SUITE 600
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3605
Practice Address - Country:US
Practice Address - Phone:213-483-9902
Practice Address - Fax:213-483-5174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23961207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty