Provider Demographics
NPI:1508589177
Name:LEFT COAST SPORTS INNOVATIONS LLC
Entity Type:Organization
Organization Name:LEFT COAST SPORTS INNOVATIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:KHORSANDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-466-9990
Mailing Address - Street 1:PO BOX 931748
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90093-1748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:403 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3720
Practice Address - Country:US
Practice Address - Phone:855-396-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-20
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier