Healthcare Provider Details

I. General information

NPI: 1477900231
Provider Name (Legal Business Name): PURE WAVE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 S BREA BLVD
BREA CA
92821-5307
US

IV. Provider business mailing address

1679 AVENIDA SELVA
FULLERTON CA
92833-1560
US

V. Phone/Fax

Practice location:
  • Phone: 714-681-2785
  • Fax:
Mailing address:
  • Phone: 714-681-2785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number16982
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number56189
License Number StateCA

VIII. Authorized Official

Name: JONGHAN KANG
Title or Position: CEO
Credential: L.AC
Phone: 714-681-2785