=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902374010
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINIMALLY INVASIVE MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2018
-----------------------------------------------------
Last Update Date | 11/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26921 CROWN VALLEY PKWY STE 120
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92691-6501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-367-1006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26921 CROWN VALLEY PKWY STE 120
-----------------------------------------------------
City | MISSION VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92691-6501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RODRIGO COVARRUBIAS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 949-367-1006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------