Provider Demographics
NPI:1104216308
Name:OWC MEDICAL CORPORATION
Entity Type:Organization
Organization Name:OWC MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE- PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, DC
Authorized Official - Phone:818-261-4208
Mailing Address - Street 1:16030 VENTURA BLVD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2731
Mailing Address - Country:US
Mailing Address - Phone:818-261-4208
Mailing Address - Fax:
Practice Address - Street 1:8820 WILSHIRE BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2620
Practice Address - Country:US
Practice Address - Phone:424-204-9001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG77858OtherCALIFORNIA MEDICAL BOARD