Provider Demographics
NPI:1780179770
Name:BEDSIDE GTUBE REPLACEMENT AND MANAGEMENT
Entity Type:Organization
Organization Name:BEDSIDE GTUBE REPLACEMENT AND MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANGMOAH
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:323-200-4524
Mailing Address - Street 1:11429 BERENDO AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-1202
Mailing Address - Country:US
Mailing Address - Phone:323-200-4524
Mailing Address - Fax:
Practice Address - Street 1:11429 BERENDO AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-1202
Practice Address - Country:US
Practice Address - Phone:323-200-4524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2022-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility