Provider Demographics
NPI:1871817460
Name:LA BREA MEDICAL CLINIC PAIN MANAGEMENT, INC
Entity Type:Organization
Organization Name:LA BREA MEDICAL CLINIC PAIN MANAGEMENT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-558-8600
Mailing Address - Street 1:3831 HUGHES AVE
Mailing Address - Street 2:705
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2751
Mailing Address - Country:US
Mailing Address - Phone:310-558-8600
Mailing Address - Fax:310-558-8650
Practice Address - Street 1:3831 HUGHES AVE
Practice Address - Street 2:705
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-2751
Practice Address - Country:US
Practice Address - Phone:310-558-8600
Practice Address - Fax:310-558-8650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61506207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG615060Medicaid
CAOOG615060Medicaid
CAG61506Medicare PIN