Healthcare Provider Details

I. General information

NPI: 1497382576
Provider Name (Legal Business Name): SHANE MICHAEL BESEDICK ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 05/28/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 WESTWOOD PLZ
LOS ANGELES CA
90095-8356
US

IV. Provider business mailing address

325 WESTWOOD PLZ
LOS ANGELES CA
90095-8356
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-3335
  • Fax:
Mailing address:
  • Phone: 310-825-3335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000001640
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: