Provider Demographics
NPI:1013943000
Name:WILLOW MEDICAL GROUP
Entity Type:Organization
Organization Name:WILLOW MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER DC
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:DOMARACKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-424-4976
Mailing Address - Street 1:3311 E WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806
Mailing Address - Country:US
Mailing Address - Phone:562-424-4976
Mailing Address - Fax:562-424-5960
Practice Address - Street 1:3311 E WILLOW ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806
Practice Address - Country:US
Practice Address - Phone:562-424-4976
Practice Address - Fax:562-424-5960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 20570111N00000X
CAG59739207LP2900X
CAA38436207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty