Healthcare Provider Details

I. General information

NPI: 1902271018
Provider Name (Legal Business Name): SHESOBUDHA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2015
Last Update Date: 12/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15402 LEIBACHER AVE
NORWALK CA
90650-5422
US

IV. Provider business mailing address

15402 LEIBACHER AVE
NORWALK CA
90650-5422
US

V. Phone/Fax

Practice location:
  • Phone: 714-986-0353
  • Fax:
Mailing address:
  • Phone: 714-986-0353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number163WX0106X
License Number StateCA

VIII. Authorized Official

Name: SHERRY LEE CLARKE
Title or Position: OCCUPATIONAL THERAPY/ HOME CARE
Credential: A OTA
Phone: 714-986-0353