Healthcare Provider Details

I. General information

NPI: 1386841278
Provider Name (Legal Business Name): VISTA BAY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21320 HAWTHORNE BLVD 207
TORRANCE CA
90503-5606
US

IV. Provider business mailing address

21320 HAWTHORNE BLVD 207
TORRANCE CA
90503-5606
US

V. Phone/Fax

Practice location:
  • Phone: 310-540-6770
  • Fax: 310-540-2004
Mailing address:
  • Phone: 310-540-6770
  • Fax: 310-540-2004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG26557
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberA22090
License Number StateCA

VIII. Authorized Official

Name: DR. JENS W DIMMICK
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 310-540-6770