Healthcare Provider Details

I. General information

NPI: 1013076496
Provider Name (Legal Business Name): BECKA HEALTHCARE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 WILSHIRE BLVD STE 1000
LOS ANGELES CA
90017-4001
US

IV. Provider business mailing address

1127 WILSHIRE BLVD STE 1000
LOS ANGELES CA
90017-4001
US

V. Phone/Fax

Practice location:
  • Phone: 213-241-0901
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG045159
License Number StateCA

VIII. Authorized Official

Name: DR. MYRON WADE BETHEL
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 213-241-0901