Provider Demographics
NPI:1215157326
Name:JEFFRIES, ROBERT MICHAEL (CO)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:JEFFRIES
Suffix:
Gender:M
Credentials:CO
Other - Prefix:MR
Other - First Name:R.
Other - Middle Name:MICHAEL
Other - Last Name:JEFFRIES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CO
Mailing Address - Street 1:PO BOX 3698
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90408-3698
Mailing Address - Country:US
Mailing Address - Phone:310-313-5874
Mailing Address - Fax:310-395-1187
Practice Address - Street 1:444 S SAN VICENTE BLVD
Practice Address - Street 2:MGB, SUITE 603
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4165
Practice Address - Country:US
Practice Address - Phone:310-313-5874
Practice Address - Fax:310-395-1187
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXA0007130Medicaid