Healthcare Provider Details

I. General information

NPI: 1073960407
Provider Name (Legal Business Name): GLENDALE REJUVENATION MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 N AVALON BLVD
WILMINGTON CA
90744-1432
US

IV. Provider business mailing address

1703 N AVALON BLVD
WILMINGTON CA
90744-1432
US

V. Phone/Fax

Practice location:
  • Phone: 310-233-9355
  • Fax: 310-233-2545
Mailing address:
  • Phone: 818-518-5980
  • Fax: 818-551-0466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. EDDIE SANTIAGO
Title or Position: MANAGER
Credential: MANAGER
Phone: 818-610-9360