Provider Demographics
NPI:1619903945
Name:COMPLETE HEALTH MEDICAL CORP
Entity Type:Organization
Organization Name:COMPLETE HEALTH MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACKSON
Authorized Official - Middle Name:C
Authorized Official - Last Name:MA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-725-1867
Mailing Address - Street 1:19745 COLIMA RD
Mailing Address - Street 2:#1-259
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-3219
Mailing Address - Country:US
Mailing Address - Phone:323-528-1565
Mailing Address - Fax:
Practice Address - Street 1:433 N 4TH ST
Practice Address - Street 2:SUITE # 216
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4311
Practice Address - Country:US
Practice Address - Phone:323-725-1867
Practice Address - Fax:323-725-1869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81950207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW20087OtherGROUP ID
CAW20087OtherGROUP ID
CAW20087Medicare PIN