Provider Demographics
NPI:1508501503
Name:LAX MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:LAX MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMSON
Authorized Official - Middle Name:
Authorized Official - Last Name:YIRGU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-867-5556
Mailing Address - Street 1:1223 WILSHIRE BLVD # 884
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5450 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094-2002
Practice Address - Country:US
Practice Address - Phone:310-867-5556
Practice Address - Fax:888-302-0594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty