Healthcare Provider Details

I. General information

NPI: 1417226804
Provider Name (Legal Business Name): BACK TO WORK ORTHOPEDIC MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 LAKEWOOD BLVD
LAKEWOOD CA
90712-2438
US

IV. Provider business mailing address

5203 LAKEWOOD BLVD
LAKEWOOD CA
90712-2438
US

V. Phone/Fax

Practice location:
  • Phone: 562-633-2273
  • Fax:
Mailing address:
  • Phone: 562-633-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: KEVIN PARK
Title or Position: MD
Credential:
Phone: 562-633-2273