Healthcare Provider Details

I. General information

NPI: 1023263555
Provider Name (Legal Business Name): GRAND MEDISPA GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13768 ROSWELL AVE STE 121
CHINO CA
91710-1404
US

IV. Provider business mailing address

13768 ROSWELL AVENUE STE 121
CHINO CA
91710-1404
US

V. Phone/Fax

Practice location:
  • Phone: 909-902-1401
  • Fax: 909-902-6317
Mailing address:
  • Phone: 909-902-1401
  • Fax: 909-902-6317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA37294
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG48262
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG48262
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA37294
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberG48262
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG48262
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberG48262
License Number StateAZ
# 8
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG48262
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberG48262
License Number StateCA
# 10
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG48262
License Number StateCA

VIII. Authorized Official

Name: THOMAS T. LEE
Title or Position: OWNER
Credential: M.D.
Phone: 909-902-1401