Healthcare Provider Details

I. General information

NPI: 1871743856
Provider Name (Legal Business Name): ELDER AUDIO REHAB MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 02/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4029 E ANAHEIM ST
LONG BEACH CA
90804-4110
US

IV. Provider business mailing address

65 PINE AVE SUITE 119
LONG BEACH CA
90802-4718
US

V. Phone/Fax

Practice location:
  • Phone: 562-494-4421
  • Fax: 562-494-2731
Mailing address:
  • Phone: 562-760-8823
  • Fax: 562-252-9505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberFNP37597
License Number StateCA

VIII. Authorized Official

Name: MR. MARSHALL EDWARD BLESOFSKY
Title or Position: PROVIDER/COO
Credential: PA-C
Phone: 562-760-8823