Provider Demographics
NPI:1104984574
Name:WALDEN SURGICAL
Entity type:Organization
Organization Name:WALDEN SURGICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-654-2299
Mailing Address - Street 1:935 N FAIRFAX AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-7203
Mailing Address - Country:US
Mailing Address - Phone:323-654-2299
Mailing Address - Fax:323-654-2299
Practice Address - Street 1:935 N FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-7203
Practice Address - Country:US
Practice Address - Phone:323-654-2299
Practice Address - Fax:323-654-2299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME02041FMedicaid
CA0281070002Medicare ID - Type UnspecifiedDURABLE MEDICAL EQUIPMENT