Healthcare Provider Details

I. General information

NPI: 1376035923
Provider Name (Legal Business Name): ALTA ORTHOPAEDIC MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2027 VILLAGE LN STE 101
SOLVANG CA
93463-2271
US

IV. Provider business mailing address

511 BATH ST
SANTA BARBARA CA
93101-3403
US

V. Phone/Fax

Practice location:
  • Phone: 805-688-8821
  • Fax: 805-962-2154
Mailing address:
  • Phone: 805-563-3307
  • Fax: 805-563-3827

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: GARY W BRADLEY
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 805-936-9377