Provider Demographics
NPI:1811013642
Name:LA VAIL
Entity Type:Organization
Organization Name:LA VAIL
Other - Org Name:NONE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERILL
Authorized Official - Middle Name:A
Authorized Official - Last Name:RADTKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-596-1452
Mailing Address - Street 1:1021 PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-6214
Mailing Address - Country:US
Mailing Address - Phone:562-596-1452
Mailing Address - Fax:562-493-2472
Practice Address - Street 1:1021 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-6214
Practice Address - Country:US
Practice Address - Phone:562-596-1452
Practice Address - Fax:562-493-2472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0742760001Medicare NSC