Provider Demographics
NPI:1790958387
Name:LOS ANGELES EAR, NOSE & THROAT ASSOCIATES
Entity Type:Organization
Organization Name:LOS ANGELES EAR, NOSE & THROAT ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-977-1215
Mailing Address - Street 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 603
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4810
Mailing Address - Country:US
Mailing Address - Phone:213-977-1215
Mailing Address - Fax:213-977-0404
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:SUITE 603
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4810
Practice Address - Country:US
Practice Address - Phone:213-977-1215
Practice Address - Fax:213-977-0404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU2778237600000X
CAHA1891237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGAU000490Medicaid