Healthcare Provider Details

I. General information

NPI: 1780179770
Provider Name (Legal Business Name): BEDSIDE GTUBE REPLACEMENT AND MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 12/17/2022
Certification Date: 12/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11429 BERENDO AVE
LOS ANGELES CA
90044-1202
US

IV. Provider business mailing address

11429 BERENDO AVE
LOS ANGELES CA
90044-1202
US

V. Phone/Fax

Practice location:
  • Phone: 323-200-4524
  • Fax:
Mailing address:
  • Phone: 323-200-4524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN SANGMOAH
Title or Position: CEO/PRESIDENT
Credential: PA
Phone: 323-200-4524