Healthcare Provider Details

I. General information

NPI: 1851263677
Provider Name (Legal Business Name): CALIFORNIA JUCO HOOPS REPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4526 CALIFORNIA AVE
LONG BEACH CA
90807-1589
US

IV. Provider business mailing address

4526 CALIFORNIA AVE
LONG BEACH CA
90807-1589
US

V. Phone/Fax

Practice location:
  • Phone: 657-427-3895
  • Fax:
Mailing address:
  • Phone: 657-427-3895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARCUS LEE BRYANT
Title or Position: MANAGER
Credential:
Phone: 657-427-3895