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General NPI Number Information
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NPI Number | 1659742252
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Entity Type | Organization
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Legal Business Name | TIMELESS MEDICINE INC
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Dates
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Enumeration Date | 10/08/2015
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Last Update Date | 10/08/2015
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Provider Practice Location Address
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Address Line | 6751 BRIDGEWATER DR
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92647-4019
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Country | US
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Telephone | 714-323-8261
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Fax |
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Provider Business Mailing Address
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Address Line | 6751 BRIDGEWATER DR
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92647-4019
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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. ROGER MIGNOSA
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Credential | D.O.
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Telephone | 714-323-8261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 20A12464
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License Number State | CA
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