Healthcare Provider Details

I. General information

NPI: 1750871752
Provider Name (Legal Business Name): PRIMARY CARE SPORTS MD GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47647 CALEO BAY DR STE 140
LA QUINTA CA
92253-8857
US

IV. Provider business mailing address

47647 CALEO BAY DR STE 140
LA QUINTA CA
92253-8857
US

V. Phone/Fax

Practice location:
  • Phone: 760-360-1000
  • Fax: 760-610-6171
Mailing address:
  • Phone: 760-360-1000
  • Fax: 760-610-6171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA121278
License Number StateCA

VIII. Authorized Official

Name: EFREN F WU
Title or Position: PRESIDENT
Credential: MD
Phone: 760-360-1000