Healthcare Provider Details

I. General information

NPI: 1831713189
Provider Name (Legal Business Name): PROSTHETIC & ORTHOTIC GROUP SAN GABRIEL VALLEY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5658 SEPULVEDA BLVD STE 206
VAN NUYS CA
91411-2951
US

IV. Provider business mailing address

5658 SEPULVEDA BLVD STE 206
VAN NUYS CA
91411-2951
US

V. Phone/Fax

Practice location:
  • Phone: 818-538-5613
  • Fax: 626-256-1405
Mailing address:
  • Phone: 818-538-5613
  • 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: GLENN MATSUSHIMA
Title or Position: CPO/OWNER
Credential:
Phone: 626-643-5063