Healthcare Provider Details

I. General information

NPI: 1699064105
Provider Name (Legal Business Name): STAR MEDICAL GROUP AND REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5524 PACIFIC BLVD
HUNTINGTON PARK CA
90255-2535
US

IV. Provider business mailing address

5524 PACIFIC BLVD
HUNTINGTON PARK CA
90255-2535
US

V. Phone/Fax

Practice location:
  • Phone: 323-581-5111
  • Fax: 323-581-5122
Mailing address:
  • Phone: 323-581-5111
  • Fax: 323-581-5122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. PETER LY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 213-200-0198