Healthcare Provider Details

I. General information

NPI: 1699955575
Provider Name (Legal Business Name): ACTIVE HEALTHCARE MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 03/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 S GLENDORA AVE
WEST COVINA CA
91790-3022
US

IV. Provider business mailing address

512 S GLENDORA AVE
WEST COVINA CA
91790-3022
US

V. Phone/Fax

Practice location:
  • Phone: 626-337-2888
  • Fax:
Mailing address:
  • Phone: 626-337-2888
  • Fax:

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 Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. MIGUEL DOMINGO
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 626-337-2888