Provider Demographics
NPI:1821314519
Name:VIBRANCE MEDICAL GROUP
Entity Type:Organization
Organization Name:VIBRANCE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:F X
Authorized Official - Last Name:CLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-866-9889
Mailing Address - Street 1:2772 TOWNSGATE RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:WESTLAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361-2903
Mailing Address - Country:US
Mailing Address - Phone:805-379-0254
Mailing Address - Fax:805-379-4541
Practice Address - Street 1:2772 TOWNSGATE RD
Practice Address - Street 2:SUITE D
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-2903
Practice Address - Country:US
Practice Address - Phone:805-379-0254
Practice Address - Fax:805-379-4541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51360302R00000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Yes302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG51360OtherSTATE MEDICAL LICENSE
CAG51360OtherSTATE MEDICAL LICENSE