=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639426067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DREAMWEAVER MEDICAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2012
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 W LAS TUNAS DR STE 1
-----------------------------------------------------
City | SAN GABRIEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91776-1213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-284-3300
-----------------------------------------------------
Fax | 626-284-3307
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 W LAS TUNAS DR STE 1
-----------------------------------------------------
City | SAN GABRIEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91776-1213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-284-3300
-----------------------------------------------------
Fax | 626-284-3307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | FRANCISCO G RODRIGUEZ
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 626-284-3300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------