Provider Demographics
NPI:1750829487
Name:MIRA MESA BUSINESS GROUP LLC
Entity Type:Organization
Organization Name:MIRA MESA BUSINESS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:DAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DUONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-380-7530
Mailing Address - Street 1:9460 MIRA MESA BLVD
Mailing Address - Street 2:SUITE L
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4851
Mailing Address - Country:US
Mailing Address - Phone:858-863-7246
Mailing Address - Fax:858-252-2650
Practice Address - Street 1:9460 MIRA MESA BLVD
Practice Address - Street 2:SUITE L
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4851
Practice Address - Country:US
Practice Address - Phone:858-863-7246
Practice Address - Fax:858-252-2650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty