Provider Demographics
NPI:1336215474
Name:SEVENTEENTH STREET ORTHOPEDIC SPECIALTY MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:SEVENTEENTH STREET ORTHOPEDIC SPECIALTY MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:R
Authorized Official - Last Name:BROURMAN
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:310-657-2202
Mailing Address - Street 1:1450 E 17TH ST
Mailing Address - Street 2:# 100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-8510
Mailing Address - Country:US
Mailing Address - Phone:714-565-1000
Mailing Address - Fax:714-565-1974
Practice Address - Street 1:1450 E 17TH ST
Practice Address - Street 2:# 100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-8510
Practice Address - Country:US
Practice Address - Phone:714-565-1000
Practice Address - Fax:714-565-1974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty