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General NPI Number Information
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NPI Number | 1003038399
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Entity Type | Organization
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Legal Business Name | COMPLETE SPINE AND WELLNESS GROUP, INC
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 12/11/2012
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Provider Practice Location Address
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Address Line | 1640 NEWPORT BLVD STE 220
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City | COSTA MESA
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State | CA
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Zip | 92627-3786
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Country | US
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Telephone | 949-650-4362
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Fax | 949-650-4366
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Provider Business Mailing Address
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Address Line | 1640 NEWPORT BLVD STE 220
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City | COSTA MESA
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State | CA
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Zip | 92627-3786
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Country | US
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Telephone | 949-650-4362
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Fax | 949-650-4366
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Authorized Official
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Title or Position | CEO
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Name | DR. MARY EBERHART
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Credential | DC, QME
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Telephone | 949-650-4362
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | DC26382
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License Number State | CA
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