1457759805 NPI number — DR. LARISSA ANN MAICHROWICZ PT, DPT

Table of content: DR. LARISSA ANN MAICHROWICZ PT, DPT (NPI 1457759805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457759805 NPI number — DR. LARISSA ANN MAICHROWICZ PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAICHROWICZ
Provider First Name:
LARISSA
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457759805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1821 WILSHIRE BLVD
Provider Second Line Business Mailing Address:
SUITE 311
Provider Business Mailing Address City Name:
SANTA MONICA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90403-5618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-453-6166
Provider Business Mailing Address Fax Number:
310-453-6154

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1821 WILSHIRE BLVD
Provider Second Line Business Practice Location Address:
SUITE 311
Provider Business Practice Location Address City Name:
SANTA MONICA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90403-5618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-453-6166
Provider Business Practice Location Address Fax Number:
310-453-6154
Provider Enumeration Date:
12/17/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  42005 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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