Organization Name: | GREAT HARBOR FAMILY & SPORTS MEDICINE, INC |
NPI Number: | 1962629162 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | ELISSA SCHLICHTER (MEDICAL DIRECTOR) |
Mailing Address: | 1294 W 6th St Suite 200 San Pedro |
State: | CA US |
Postal Code: | 907312987 |
Phone Number: | 3105211311 |
Fax Number: | 3105141313 |
NPI Enumeration Date: | 04/19/2007 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | 20A7368 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | CA |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |