Provider Demographics
NPI:1871179085
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:CP, BOCPO
Authorized Official - Phone:323-727-2887
Mailing Address - Street 1:3625 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 1:3000 W OLYMPIC BLVD
Practice Address - Street 2:#301
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006
Practice Address - Country:US
Practice Address - Phone:213-351-3556
Practice Address - Fax:213-351-3558
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEVERLY ORTHOPEDIC LABORATORY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC000815Medicaid