=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346740941
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | B.S.P. PROFESSIONAL SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2018
-----------------------------------------------------
Last Update Date | 02/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1197 N ARBOR ST APT OR
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92801-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-956-5575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3774
-----------------------------------------------------
City | FULLERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92834-3774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-956-5575
-----------------------------------------------------
Fax | 714-956-5575
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BELLA PANCHAL
-----------------------------------------------------
Credential | AU.D. M.SC.CCC-A/SLP
-----------------------------------------------------
Telephone | 714-956-5575
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AUD1424
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SLP8464
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------