Healthcare Provider Details

I. General information

NPI: 1821751520
Provider Name (Legal Business Name): COMPLETE PERFORMANCE SPORTS MEDICINE AND LONGEVITY CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HODENCAMP RD
THOUSAND OAKS CA
91360-5836
US

IV. Provider business mailing address

101 HODENCAMP RD
THOUSAND OAKS CA
91360-5836
US

V. Phone/Fax

Practice location:
  • Phone: 805-777-7003
  • Fax: 805-777-7043
Mailing address:
  • Phone: 805-777-7003
  • Fax: 805-777-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRIS ALVAREZ
Title or Position: OWNER
Credential:
Phone: 805-777-7003