Healthcare Provider Details

I. General information

NPI: 1902238678
Provider Name (Legal Business Name): BEVERLY HILLS FITNESS GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13535 VALLEYHEART DR N
SHERMAN OAKS CA
91423-3123
US

IV. Provider business mailing address

13535 VALLEYHEART DR N
SHERMAN OAKS CA
91423-3123
US

V. Phone/Fax

Practice location:
  • Phone: 310-927-2162
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberA052594
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberA052594
License Number StateCA

VIII. Authorized Official

Name: LEON JEREMY LAVIGNE
Title or Position: PRESIDENT
Credential:
Phone: 310-927-2162