Healthcare Provider Details

I. General information

NPI: 1083306773
Provider Name (Legal Business Name): LEBREOOT A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9171 WILSHIRE BLVD STE 500
BEVERLY HILLS CA
90210-5536
US

IV. Provider business mailing address

9171 WILSHIRE BLVD STE 500
BEVERLY HILLS CA
90210-5536
US

V. Phone/Fax

Practice location:
  • Phone: 310-331-0077
  • Fax: 213-582-8811
Mailing address:
  • Phone: 310-331-0077
  • Fax: 213-582-8811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JOOBIN A SHEMTOV
Title or Position: CEO
Credential:
Phone: 310-999-7098