Provider Demographics
NPI:1366436396
Name:IRVINE PHYSICAL MEDICINE & REHABILITATION A MEDICAL CORPORATION
Entity type:Organization
Organization Name:IRVINE PHYSICAL MEDICINE & REHABILITATION A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DAIZY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-552-9393
Mailing Address - Street 1:18124 CULVER DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2729
Mailing Address - Country:US
Mailing Address - Phone:949-552-9393
Mailing Address - Fax:949-552-5872
Practice Address - Street 1:18124 CULVER DR
Practice Address - Street 2:SUITE F
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-2729
Practice Address - Country:US
Practice Address - Phone:949-552-9393
Practice Address - Fax:949-552-5872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24241111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16704Medicare PIN