Basic Information
| Provider Information | |||||||||
| NPI: | 1861539280 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONSERVATIVE CARE SPECIALISTS MEDICAL GROUP INC | ||||||||
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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 | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187816684 | ||||||||
| FaxNumber: | 8187814457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 05/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | HYMES | ||||||||
| AuthorizedOfficialFirstName: | JAYSON | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8187816684 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONSERVATIVE CARE SPECIALISTS MEDICAL GROUP INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | G056728 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0065790 | 05 | CA | MEDICAID |