1477792901 NPI number — BEVERLY HILLS SPORTS MEDICINE GROUP, INC.

Table of content: (NPI 1477792901)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477792901 NPI number — BEVERLY HILLS SPORTS MEDICINE GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEVERLY HILLS SPORTS MEDICINE GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477792901
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23852 PACIFIC COAST HWY
Provider Second Line Business Mailing Address:
441
Provider Business Mailing Address City Name:
MALIBU
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90265-4879
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-828-1522
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9478 W OLYMPIC BLVD
Provider Second Line Business Practice Location Address:
307
Provider Business Practice Location Address City Name:
BEVERLY HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90212-4246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-785-9123
Provider Business Practice Location Address Fax Number:
206-202-4724
Provider Enumeration Date:
02/06/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KAYE
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
310-828-1522

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  G7818 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: G29768 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)