Healthcare Provider Details

I. General information

NPI: 1740733724
Provider Name (Legal Business Name): CAPITAL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 SHATTO PL SUITE 419
LOS ANGELES CA
90020-1793
US

IV. Provider business mailing address

440 SHATTO PL SUITE 419
LOS ANGELES CA
90020-1793
US

V. Phone/Fax

Practice location:
  • Phone: 562-632-1027
  • Fax:
Mailing address:
  • Phone: 562-632-1027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberC31257
License Number StateCA

VIII. Authorized Official

Name: RICHARRD HENRY HUBBARD
Title or Position: PRESIDENT
Credential:
Phone: 562-632-1027