Provider Demographics
NPI:1952496572
Name:VA GREATER LOS ANGELES MEDICAL CENTER
Entity Type:Organization
Organization Name:VA GREATER LOS ANGELES MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:KINESIOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:WALLACE
Authorized Official - Last Name:EISNER
Authorized Official - Suffix:
Authorized Official - Credentials:RKT
Authorized Official - Phone:310-478-3711
Mailing Address - Street 1:12122 EXCELSIOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650
Mailing Address - Country:US
Mailing Address - Phone:562-863-6315
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1031283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital