Healthcare Provider Details

I. General information

NPI: 1508501503
Provider Name (Legal Business Name): LAX MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5450 LINCOLN BLVD
PLAYA VISTA CA
90094-2002
US

IV. Provider business mailing address

1223 WILSHIRE BLVD # 884
SANTA MONICA CA
90403-5406
US

V. Phone/Fax

Practice location:
  • Phone: 310-867-5556
  • Fax: 888-302-0594
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SAMSON YIRGU
Title or Position: PRESIDENT
Credential:
Phone: 310-867-5556