=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700445871
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RENEWED STRENGTH MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13252 GARDEN GROVE BLVD STE 112
-----------------------------------------------------
City | GARDEN GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92843-2270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-740-1778
-----------------------------------------------------
Fax | 714-740-1913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21707 HAWTHORNE BLVD STE 201
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90503-7012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-792-2426
-----------------------------------------------------
Fax | 310-540-9486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS ADMINISTRATOR
-----------------------------------------------------
Name | JESSE E FINLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-792-2430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------