Healthcare Provider Details

I. General information

NPI: 1003917048
Provider Name (Legal Business Name): CHILDREN'S MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/01/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3440 W. LOMITA BLVD. SUITE 352
TORRANCE CA
90505-4858
US

IV. Provider business mailing address

3440 LOMITA BLVD STE 352
TORRANCE CA
90505-4821
US

V. Phone/Fax

Practice location:
  • Phone: 310-539-2445
  • Fax: 310-539-0061
Mailing address:
  • Phone: 310-539-2445
  • Fax: 310-539-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG13850
License Number StateCA

VIII. Authorized Official

Name: LAURA SERGIS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 310-539-2445