Provider Demographics
NPI:1558370023
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
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:S
Authorized Official - Last Name:KAWANKAR
Authorized Official - Suffix:
Authorized Official - Credentials:CP, BOCPO
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:323-727-2887
Mailing Address - Fax:323-727-2854
Practice Address - Street 1:2625 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640
Practice Address - Country:US
Practice Address - Phone:323-727-2887
Practice Address - Fax:323-727-2854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXCOOO8150Medicaid
CAZZZ02896ZOtherBLUE SHIELD OF CALIFORNIA
0293250001Medicare ID - Type Unspecified