Provider Demographics
NPI:1205655644
Name:PREMIERE SPINE AND SPORTS MEDICINE
Entity type:Organization
Organization Name:PREMIERE SPINE AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DONG HYUN
Authorized Official - Middle Name:
Authorized Official - Last Name:GWAG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:714-334-6211
Mailing Address - Street 1:2255 E MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-6508
Mailing Address - Country:US
Mailing Address - Phone:310-322-8777
Mailing Address - Fax:310-322-8787
Practice Address - Street 1:2255 E MAPLE AVE
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-6508
Practice Address - Country:US
Practice Address - Phone:310-322-8777
Practice Address - Fax:310-322-8787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty