Healthcare Provider Details

I. General information

NPI: 1679615496
Provider Name (Legal Business Name): JOHN J.R., M.D., A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 N SEPULVEDA BLVD
MANHATTAN BEACH CA
90266-2727
US

IV. Provider business mailing address

210 ANDERSON ST
MANHATTAN BEACH CA
90266-6610
US

V. Phone/Fax

Practice location:
  • Phone: 310-796-4509
  • Fax:
Mailing address:
  • Phone: 310-796-4509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberA25323
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN REHM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-796-4509