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General NPI Number Information
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NPI Number | 1205655644
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Entity Type | Organization
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Legal Business Name | PREMIERE SPINE AND SPORTS MEDICINE
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Dates
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Enumeration Date | 10/03/2024
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Last Update Date | 10/03/2024
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Provider Practice Location Address
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Address Line | 2255 E MAPLE AVE
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City | EL SEGUNDO
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State | CA
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Zip | 90245-6508
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Country | US
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Telephone | 310-322-8777
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Fax | 310-322-8787
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Provider Business Mailing Address
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Address Line | 2255 E MAPLE AVE
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City | EL SEGUNDO
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State | CA
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Zip | 90245-6508
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Country | US
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Telephone | 310-322-8777
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Fax | 310-322-8787
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Authorized Official
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Title or Position | OWNER/CHIROPRACTOR
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Name | DR. DONG HYUN GWAG
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Credential | DC
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Telephone | 714-334-6211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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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 | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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