Basic Information
| Provider Information | |||||||||
| NPI: | 1063828911 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONSERVATIVE CARE SPECIALIST MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5486 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928635486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185500900 | ||||||||
| FaxNumber: | 3039538260 | ||||||||
| Practice Location | |||||||||
| Address1: | 6815 NOBLE AVE STE 105 | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187816684 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2014 | ||||||||
| LastUpdateDate: | 07/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | MEHRER | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8185500900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONSERVATIVE CARE SPECIALIST MEDICAL GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G056728 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.