Healthcare Provider Details

I. General information

NPI: 1356886980
Provider Name (Legal Business Name): MARIA KSENDZOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MANYA KSENDZOV BA

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 N PRAIRIE AVE
INGLEWOOD CA
90301-4502
US

IV. Provider business mailing address

4760 SEPULVEDA BLVD
CULVER CITY CA
90230-4820
US

V. Phone/Fax

Practice location:
  • Phone: 310-846-2100
  • Fax: 310-846-2139
Mailing address:
  • Phone: 310-390-6612
  • Fax: 310-398-5690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number1356886980
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: