Healthcare Provider Details

I. General information

NPI: 1104153113
Provider Name (Legal Business Name): ORANGE COUNTY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2009
Last Update Date: 11/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 W LA PALMA AVE STE 709
ANAHEIM CA
92801-2814
US

IV. Provider business mailing address

1211 W LA PALMA AVE STE 709
ANAHEIM CA
92801-2814
US

V. Phone/Fax

Practice location:
  • Phone: 714-808-9292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberG84446
License Number StateCA

VIII. Authorized Official

Name: ROSEANN GONZALEZ
Title or Position: PRESIDENT
Credential:
Phone: 714-808-9292