Healthcare Provider Details

I. General information

NPI: 1487359832
Provider Name (Legal Business Name): BEVERLY ORTHOPEDIC LABORATORY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 LATHAM STREET SUITE:G
RIVERSIDE CA
92501-0001
US

IV. Provider business mailing address

2625 W BEVERLY BLVD
MONTEBELLO CA
90640-0031
US

V. Phone/Fax

Practice location:
  • Phone: 951-742-5127
  • Fax: 951-742-5184
Mailing address:
  • Phone: 323-727-2887
  • Fax: 323-727-2854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. SANJAY S KAWANKAR
Title or Position: CEO/CFO
Credential: CP, BOCPO
Phone: 323-727-2887