Healthcare Provider Details

I. General information

NPI: 1063233732
Provider Name (Legal Business Name): PREMIERE CHIROPRACTIC AND PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2024
Last Update Date: 10/24/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S MAIN ST. UNIT 210
CORONA CA
92882
US

IV. Provider business mailing address

900 S MAIN ST. UNIT 210
CORONA CA
92882
US

V. Phone/Fax

Practice location:
  • Phone: 714-334-6211
  • Fax:
Mailing address:
  • Phone: 714-334-6211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. DONG HYUN GWAG
Title or Position: OWNER
Credential: DC
Phone: 714-334-6211