Provider Demographics
NPI:1073960407
Name:GLENDALE REJUVENATION MEDICAL GROUP
Entity Type:Organization
Organization Name:GLENDALE REJUVENATION MEDICAL GROUP
Other - Org Name:GLENDALE REJUVENATION MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGER
Authorized Official - Phone:818-610-9360
Mailing Address - Street 1:1703 N AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-1432
Mailing Address - Country:US
Mailing Address - Phone:818-518-5980
Mailing Address - Fax:818-551-0466
Practice Address - Street 1:1703 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-1432
Practice Address - Country:US
Practice Address - Phone:310-233-9355
Practice Address - Fax:310-233-2545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-16
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty