Provider Demographics
NPI:1033467337
Name:EASTERN MEDICAL GROUP
Entity Type:Organization
Organization Name:EASTERN MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, DC
Authorized Official - Phone:714-669-9088
Mailing Address - Street 1:1076 E 1ST ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3852
Mailing Address - Country:US
Mailing Address - Phone:714-669-9088
Mailing Address - Fax:
Practice Address - Street 1:1076 E 1ST ST
Practice Address - Street 2:SUITE G
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3852
Practice Address - Country:US
Practice Address - Phone:714-669-9088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC31707111N00000X
CAAC13964171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty