Provider Demographics
NPI:1659913291
Name:SOLANDSOUL MEDICAL GROUP, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SOLANDSOUL MEDICAL GROUP, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:LUZWAVE INTEGRATIVE MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-527-6400
Mailing Address - Street 1:14642 NEWPORT AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6058
Mailing Address - Country:US
Mailing Address - Phone:949-527-6400
Mailing Address - Fax:714-486-2309
Practice Address - Street 1:14642 NEWPORT AVE STE 105
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6058
Practice Address - Country:US
Practice Address - Phone:949-527-6410
Practice Address - Fax:714-486-2309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-15
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty