Provider Demographics
NPI:1982875860
Name:WEST BEVERLY MEDICAL CORPORATION
Entity Type:Organization
Organization Name:WEST BEVERLY MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONIO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:323-461-4183
Mailing Address - Street 1:4643 BEVERLY BLVD
Mailing Address - Street 2:#103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3101
Mailing Address - Country:US
Mailing Address - Phone:323-461-4183
Mailing Address - Fax:323-461-0864
Practice Address - Street 1:4643 BEVERLY BLVD
Practice Address - Street 2:#103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3101
Practice Address - Country:US
Practice Address - Phone:323-461-4183
Practice Address - Fax:323-461-0864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13826Medicare PIN
CAA83326Medicare UPIN