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General NPI Number Information
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NPI Number | 1124630967
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Entity Type | Organization
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Legal Business Name | INJURED WORKERS MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 08/22/2020
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4600 CAMPUS DR STE 108
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City | NEWPORT BEACH
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State | CA
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Zip | 92660-1885
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Country | US
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Telephone | 949-769-6071
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Fax |
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Provider Business Mailing Address
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Address Line | 14252 CULVER DR STE 295
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City | IRVINE
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State | CA
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Zip | 92604-0317
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. VRIJESH SHANTANU TANTUWAYA
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Credential | MD
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Telephone | 858-472-1380
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NX0100X
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Taxonomy Name | Occupational Health Chiropractor
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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 | 261QX0100X
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Taxonomy Name | Occupational Medicine Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number |
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License Number State |
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