MEDICARE: PROSTHETIC & ORTHOTIC GROUP SAN GABRIEL VALLEY, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

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

Provider Business Mailing Address
First Line	:	5658 SEPULVEDA BLVD STE 206
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91411-2951
Country	:	US
Telephone Number	:	818-538-5613
Fax Number	:

Provider Business Practice Location Address
First Line	:	5658 SEPULVEDA BLVD STE 206
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91411-2951
Country	:	US
Telephone Number	:	818-538-5613
Fax Number	:	626-256-1405

Authorized Official
Title or Position	:	CPO/OWNER
Name	:	GLENN MATSUSHIMA
Credential	:
Telephone Number	:	626-643-5063

Provider Enumeration Date	:	06/02/2020
Last Update Date	:	09/15/2025

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