Healthcare Provider Details

I. General information

NPI: 1184588147
Provider Name (Legal Business Name): SHENDRA MATHIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

897 KINCAID AVE
INGLEWOOD CA
90302-2005
US

IV. Provider business mailing address

11140 JEFFERSON BLVD STE 4
CULVER CITY CA
90230-5522
US

V. Phone/Fax

Practice location:
  • Phone: 323-384-2212
  • Fax:
Mailing address:
  • Phone: 323-384-2212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: