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General NPI Number Information
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NPI Number | 1760532543
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Entity Type | Organization
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Legal Business Name | COLLEGE MEDICAL GROUP, INC.
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 611 S MAIN ST SUITE A
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City | SANTA ANA
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State | CA
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Zip | 92701-5715
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Country | US
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Telephone | 714-564-9323
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Fax | 714-973-8885
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Provider Business Mailing Address
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Address Line | 611 S MAIN ST SUITE A
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City | SANTA ANA
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State | CA
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Zip | 92701-5715
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Country | US
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Telephone | 714-564-9323
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Fax | 714-973-8885
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SOMSONG WATTANASAKUL TONGBAI
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Credential | M.D.
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Telephone | 714-564-9323
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | A31437
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License Number State | CA
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