Healthcare Provider Details

I. General information

NPI: 1043572076
Provider Name (Legal Business Name): TOTAL BODY HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 03/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24401 MUIRLANDS BLVD STE C
LAKE FOREST CA
92630-3949
US

IV. Provider business mailing address

1057 E IMPERIAL HWY SUITE 614
PLACENTIA CA
92870-1717
US

V. Phone/Fax

Practice location:
  • Phone: 949-855-8845
  • Fax: 949-855-9167
Mailing address:
  • Phone: 714-293-4060
  • Fax: 714-577-9020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG81865
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberG81865
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberG81865
License Number StateCA

VIII. Authorized Official

Name: DR. CHYLE E BEAIRD
Title or Position: CEO/MEDICAL DIRECTOR
Credential: M.D.
Phone: 949-855-8845