Healthcare Provider Details

I. General information

NPI: 1972694487
Provider Name (Legal Business Name): 436 BEVERLY HILLS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 N BEDFORD DR SUITE 102
BEVERLY HILLS CA
90210-4310
US

IV. Provider business mailing address

436 N BEDFORD DR SUITE 102
BEVERLY HILLS CA
90210-4310
US

V. Phone/Fax

Practice location:
  • Phone: 310-278-8200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA BENKE CASSILETH
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 310-278-8200