Healthcare Provider Details

I. General information

NPI: 1013943000
Provider Name (Legal Business Name): WILLOW MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 01/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 E WILLOW ST
LONG BEACH CA
90806
US

IV. Provider business mailing address

3311 E WILLOW ST
LONG BEACH CA
90806
US

V. Phone/Fax

Practice location:
  • Phone: 562-424-4976
  • Fax: 562-424-5960
Mailing address:
  • Phone: 562-424-4976
  • Fax: 562-424-5960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG59739
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberA38436
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC 20570
License Number StateCA

VIII. Authorized Official

Name: LAWRENCE J DOMARACKI
Title or Position: CO-OWNER DC
Credential:
Phone: 562-424-4976