=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760044937
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GENNADIY YESHU OTR/L
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2019
-----------------------------------------------------
Last Update Date | 07/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7188 W SUNSET BLVD STE 200
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90046-4446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-927-9254
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11910 WEDDINGTON ST UNIT 102
-----------------------------------------------------
City | VALLEY VILLAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91607-4402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 20143
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------