Healthcare Provider Details

I. General information

NPI: 1720295744
Provider Name (Legal Business Name): CONCENTRA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 CENTERPOINTE DR 115
LA PALMA CA
90623-1072
US

IV. Provider business mailing address

26 CENTERPOINTE DR 115
LA PALMA CA
90623-1072
US

V. Phone/Fax

Practice location:
  • Phone: 714-522-8051
  • Fax: 714-522-5703
Mailing address:
  • Phone: 714-522-8051
  • Fax: 714-522-5703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License NumberAT3551
License Number StateCA

VIII. Authorized Official

Name: MR. JAY MYRON FULLER
Title or Position: PHYSICAL THERAPIST ASSISTANT
Credential: PTA
Phone: 714-522-8051