Healthcare Provider Details

I. General information

NPI: 1124630967
Provider Name (Legal Business Name): INJURED WORKERS MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

4600 CAMPUS DR STE 108
NEWPORT BEACH CA
92660-1885
US

IV. Provider business mailing address

14252 CULVER DR STE 295
IRVINE CA
92604-0317
US

V. Phone/Fax

Practice location:
  • Phone: 949-769-6071
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. VRIJESH SHANTANU TANTUWAYA
Title or Position: PRESIDENT
Credential: MD
Phone: 858-472-1380