Healthcare Provider Details

I. General information

NPI: 1871916494
Provider Name (Legal Business Name): GREATER LONG BEACH PERIPHERAL ARTERIAL DISEASE CENTER, A PROFESSIONAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 W HAWTHORN PKWY SUITE 410
VERNON HILLS IL
60061-1446
US

IV. Provider business mailing address

16506 LAKEWOOD BLVD SUITE 200
BELLFLOWER CA
90706-5164
US

V. Phone/Fax

Practice location:
  • Phone: 847-388-2001
  • Fax: 847-388-2020
Mailing address:
  • Phone: 562-867-5300
  • Fax: 562-867-8666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ARVIND MEHTA
Title or Position: PRESIDENT
Credential: MD
Phone: 562-867-5300