Healthcare Provider Details

I. General information

NPI: 1780163915
Provider Name (Legal Business Name): COMPLETE SPINE AND JOINT CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15112 ROSECRANS AVE
LA MIRADA CA
90638
US

IV. Provider business mailing address

15112 ROSECRANS AVE
LA MIRADA CA
90638-4742
US

V. Phone/Fax

Practice location:
  • Phone: 714-522-2332
  • Fax: 714-522-2344
Mailing address:
  • Phone: 714-522-2332
  • Fax: 714-522-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC23913
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberA36925
License Number StateCA

VIII. Authorized Official

Name: GREGORY WARREN MIDDLETON
Title or Position: PRESIDENT
Credential: D.C
Phone: 714-522-2332