Healthcare Provider Details

I. General information

NPI: 1710261284
Provider Name (Legal Business Name): BELLA MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2933 WHITTIER BLVD
LOS ANGELES CA
90023-1528
US

IV. Provider business mailing address

2933 WHITTIER BLVD
LOS ANGELES CA
90023-1528
US

V. Phone/Fax

Practice location:
  • Phone: 323-263-2669
  • Fax: 323-263-2673
Mailing address:
  • Phone: 323-263-2669
  • Fax: 323-263-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA73468
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA60865
License Number StateCA

VIII. Authorized Official

Name: JOSE SERGIO SANDOVAL
Title or Position: AUTHORIZED OFFICIAL
Credential: PA-C
Phone: 562-716-5620