Provider Demographics
NPI:1063828911
Name:CONSERVATIVE CARE SPECIALIST MEDICAL GROUP
Entity Type:Organization
Organization Name:CONSERVATIVE CARE SPECIALIST MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHRER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-550-0900
Mailing Address - Street 1:PO BOX 5486
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5486
Mailing Address - Country:US
Mailing Address - Phone:818-550-0900
Mailing Address - Fax:303-953-8260
Practice Address - Street 1:6815 NOBLE AVE STE 105
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405
Practice Address - Country:US
Practice Address - Phone:818-781-6684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONSERVATIVE CARE SPECIALIST MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-10
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG056728174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty