Provider Demographics
NPI:1306090824
Name:LONG BEACH VAMC
Entity type:Organization
Organization Name:LONG BEACH VAMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED RESPIRATORY THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:CRTT
Authorized Official - Phone:562-826-8000
Mailing Address - Street 1:10182 LAMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4715
Mailing Address - Country:US
Mailing Address - Phone:714-530-7283
Mailing Address - Fax:
Practice Address - Street 1:5901 E 7TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90822-5201
Practice Address - Country:US
Practice Address - Phone:562-826-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADISCONTINUED283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital