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General NPI Number Information
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NPI Number | 1073960407
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Entity Type | Organization
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Legal Business Name | GLENDALE REJUVENATION MEDICAL GROUP
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Dates
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Enumeration Date | 05/16/2016
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Last Update Date | 12/21/2021
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Provider Practice Location Address
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Address Line | 1703 N AVALON BLVD
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City | WILMINGTON
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State | CA
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Zip | 90744-1432
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Country | US
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Telephone | 310-233-9355
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Fax | 310-233-2545
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Provider Business Mailing Address
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Address Line | 1703 N AVALON BLVD
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City | WILMINGTON
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State | CA
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Zip | 90744-1432
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Country | US
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Telephone | 818-518-5980
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Fax | 818-551-0466
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Authorized Official
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Title or Position | MANAGER
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Name | MR. EDDIE SANTIAGO
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Credential | MANAGER
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Telephone | 818-610-9360
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 111NN1001X
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Taxonomy Name | Nutrition Chiropractor
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License Number |
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Taxonomy #3
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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Taxonomy #4
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number |
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Taxonomy #5
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Taxonomy Code | 2083S0010X
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Taxonomy Name | Sports Medicine (Preventive Medicine) Physician
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License Number |
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Taxonomy #6
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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Taxonomy #7
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 207QB0002X
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Taxonomy Name | Obesity Medicine (Family Medicine) Physician
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License Number |
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