Provider Demographics
NPI:1326698937
Name:SEAN, PETER (CPO)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:SEAN
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 W OLYMPIC BLVD STE 123
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-3734
Mailing Address - Country:US
Mailing Address - Phone:213-383-9212
Mailing Address - Fax:
Practice Address - Street 1:1830 W OLYMPIC BLVD STE 123
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-3734
Practice Address - Country:US
Practice Address - Phone:213-383-9212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000070Medicaid