Healthcare Provider Details

I. General information

NPI: 1205655644
Provider Name (Legal Business Name): PREMIERE SPINE AND SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 E MAPLE AVE
EL SEGUNDO CA
90245-6508
US

IV. Provider business mailing address

2255 E MAPLE AVE
EL SEGUNDO CA
90245-6508
US

V. Phone/Fax

Practice location:
  • Phone: 310-322-8777
  • Fax: 310-322-8787
Mailing address:
  • Phone: 310-322-8777
  • Fax: 310-322-8787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

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