1831713189 NPI number — PROSTHETIC & ORTHOTIC GROUP SAN GABRIEL VALLEY, INC

Table of content: GRACE BERNER (NPI 1073102570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831713189 NPI number — PROSTHETIC & ORTHOTIC GROUP SAN GABRIEL VALLEY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROSTHETIC & ORTHOTIC GROUP SAN GABRIEL VALLEY, 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:
1831713189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5658 SEPULVEDA BLVD STE 206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VAN NUYS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91411-2951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-538-5613
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5658 SEPULVEDA BLVD STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VAN NUYS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91411-2951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-538-5613
Provider Business Practice Location Address Fax Number:
626-256-1405
Provider Enumeration Date:
06/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
RODRIGUEZ
Authorized Official First Name:
MARK
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CPO/OWNER
Authorized Official Telephone Number:
626-643-5063

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1548718612 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com