Healthcare Provider Details

I. General information

NPI: 1508589177
Provider Name (Legal Business Name): LEFT COAST SPORTS INNOVATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 E WASHINGTON BLVD
LOS ANGELES CA
90015-3720
US

IV. Provider business mailing address

PO BOX 931748
LOS ANGELES CA
90093-1748
US

V. Phone/Fax

Practice location:
  • Phone: 855-396-8800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. JACK KHORSANDI
Title or Position: MBR
Credential:
Phone: 310-466-9990