Provider Demographics
NPI:1407449648
Name:BEVERLY ORTHOPEDIC LABORATORY INC
Entity Type:Organization
Organization Name:BEVERLY ORTHOPEDIC LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO / CFO PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:SURESH
Authorized Official - Last Name:KAWANKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-727-2887
Mailing Address - Street 1:2625 W. BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 N. TUSTIN AVE
Practice Address - Street 2:#203
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705
Practice Address - Country:US
Practice Address - Phone:657-247-4301
Practice Address - Fax:657-247-4320
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEVERLY ORTHOPEDIC LABORATORY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0008150Medicaid