Healthcare Provider Details

I. General information

NPI: 1003038399
Provider Name (Legal Business Name): COMPLETE SPINE AND WELLNESS GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 NEWPORT BLVD STE 220
COSTA MESA CA
92627-3786
US

IV. Provider business mailing address

1640 NEWPORT BLVD STE 220
COSTA MESA CA
92627-3786
US

V. Phone/Fax

Practice location:
  • Phone: 949-650-4362
  • Fax: 949-650-4366
Mailing address:
  • Phone: 949-650-4362
  • Fax: 949-650-4366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC26382
License Number StateCA

VIII. Authorized Official

Name: DR. MARY EBERHART
Title or Position: CEO
Credential: DC, QME
Phone: 949-650-4362