Healthcare Provider Details

I. General information

NPI: 1033736848
Provider Name (Legal Business Name): SUE SEAN CP CFM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 W OLYMPIC BLVD STE 123
LOS ANGELES CA
90006-3734
US

IV. Provider business mailing address

1830 W OLYMPIC BLVD STE 123
LOS ANGELES CA
90006-3734
US

V. Phone/Fax

Practice location:
  • Phone: 213-383-9212
  • Fax: 213-383-6421
Mailing address:
  • Phone: 213-383-9212
  • Fax: 213-383-6421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License NumberCFM02641
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCP003476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: