Healthcare Provider Details

I. General information

NPI: 1174660161
Provider Name (Legal Business Name): PERFORMANCE HEALTH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13252 GARDEN GROVE BLVD SUITE 112
GARDEN GROVE CA
92843-2204
US

IV. Provider business mailing address

21707 HAWTHORNE BLVD STE 201
TORRANCE CA
90503
US

V. Phone/Fax

Practice location:
  • Phone: 714-740-1778
  • Fax: 714-740-1913
Mailing address:
  • Phone: 310-540-9699
  • Fax: 310-540-9486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN D CARRICO
Title or Position: OWNER
Credential: DC
Phone: 310-540-9699