MEDICARE: COMPLETE SPINE AND WELLNESS GROUP, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NR0400X	Rehabilitation Chiropractor	DC26382	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1639319924	OTHER	CA	NPI

General Provider Information

NPI Number	:	1003038399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPLETE SPINE AND WELLNESS GROUP, INC

Provider Business Mailing Address
First Line	:	1640 NEWPORT BLVD STE 220
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-3786
Country	:	US
Telephone Number	:	949-650-4362
Fax Number	:	949-650-4366

Provider Business Practice Location Address
First Line	:	1640 NEWPORT BLVD STE 220
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-3786
Country	:	US
Telephone Number	:	949-650-4362
Fax Number	:	949-650-4366

Authorized Official
Title or Position	:	CEO
Name	:	DR. MARY EBERHART
Credential	:	DC, QME
Telephone Number	:	949-650-4362

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	12/11/2012

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