Provider Demographics
NPI:1881899391
Name:PRENTICE MITRI & HIJAZIN
Entity type:Organization
Organization Name:PRENTICE MITRI & HIJAZIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:C
Authorized Official - Last Name:PRENTICE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:562-861-1988
Mailing Address - Street 1:10916 DOWNEY AVE
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3709
Mailing Address - Country:US
Mailing Address - Phone:562-861-1988
Mailing Address - Fax:562-861-5835
Practice Address - Street 1:10916 DOWNEY AVE
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3709
Practice Address - Country:US
Practice Address - Phone:562-861-1988
Practice Address - Fax:562-861-5835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38015174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty