Healthcare Provider Details

I. General information

NPI: 1174683643
Provider Name (Legal Business Name): ORTHOPAEDIC MEDICAL GROUP & ATHLETIC REHABILITATION CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 LAKES DR STE 100
WEST COVINA CA
91790
US

IV. Provider business mailing address

1050 LAKES DR STE 100
WEST COVINA CA
91790-2929
US

V. Phone/Fax

Practice location:
  • Phone: 626-918-6655
  • Fax: 626-918-6633
Mailing address:
  • Phone: 626-918-6655
  • Fax: 626-918-6633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: THOMAS O BRYAN
Title or Position: PRESIDENT
Credential: MD
Phone: 626-918-6655