MEDICARE: WILLOW MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP2900X	Pain Medicine (Anesthesiology) Physician	G59739	CA
2	207XS0117X	Orthopaedic Surgery of the Spine Physician	A38436	CA
3	111N00000X	Chiropractor	DC 20570	CA

General Provider Information

NPI Number	:	1013943000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW MEDICAL GROUP

Provider Business Mailing Address
First Line	:	3311 E WILLOW ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806
Country	:	US
Telephone Number	:	562-424-4976
Fax Number	:	562-424-5960

Provider Business Practice Location Address
First Line	:	3311 E WILLOW ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806
Country	:	US
Telephone Number	:	562-424-4976
Fax Number	:	562-424-5960

Authorized Official
Title or Position	:	CO-OWNER DC
Name	:	LAWRENCE J DOMARACKI
Credential	:
Telephone Number	:	562-424-4976

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	01/04/2008

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