Healthcare Provider Details

I. General information

NPI: 1760949044
Provider Name (Legal Business Name): CHRONIC CARE MANAGEMENT GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 02/28/2020
Certification Date: 02/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3756 SANTA ROSALIA DR STE 505
LOS ANGELES CA
90008-3656
US

IV. Provider business mailing address

5 HOLLAND STE 101
IRVINE CA
92618-2568
US

V. Phone/Fax

Practice location:
  • Phone: 323-903-5452
  • Fax:
Mailing address:
  • Phone: 949-588-2190
  • Fax: 949-588-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: BROWNELL PAYNE
Title or Position: PRESIDENT
Credential: MD
Phone: 949-588-2190