Provider Demographics
NPI:1538175997
Name:WEST BEVERLY PODIATRY GROUP, INC
Entity type:Organization
Organization Name:WEST BEVERLY PODIATRY GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-721-6026
Mailing Address - Street 1:1417 W BEVERLY BLVD
Mailing Address - Street 2:104
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4123
Mailing Address - Country:US
Mailing Address - Phone:323-721-6026
Mailing Address - Fax:323-887-1891
Practice Address - Street 1:638 W DUARTE RD STE 7
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-9201
Practice Address - Country:US
Practice Address - Phone:626-447-5122
Practice Address - Fax:626-447-5272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADA3847OtherRAILROAD
CAGRE000310Medicaid
CA480003204OtherRAILROAD MEDICARE
CAW12208AMedicare ID - Type Unspecified
CAGRE000310Medicaid