Provider Demographics
NPI:1760679104
Name:NATH, PREM (MSC)
Entity Type:Individual
Prefix:MR
First Name:PREM
Middle Name:
Last Name:NATH
Suffix:
Gender:M
Credentials:MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 W OLYMPIC BLVD
Mailing Address - Street 2:101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90036-4855
Mailing Address - Country:US
Mailing Address - Phone:323-379-7189
Mailing Address - Fax:323-379-7189
Practice Address - Street 1:5601 W OLYMPIC BLVD
Practice Address - Street 2:101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4855
Practice Address - Country:US
Practice Address - Phone:323-379-7189
Practice Address - Fax:323-379-7189
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP13467235Z00000X
CAAU 3073231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist