Provider Demographics
NPI:1356916290
Name:MYOFASCIAL RESTORATION AND INTEGRATION POMC
Entity type:Organization
Organization Name:MYOFASCIAL RESTORATION AND INTEGRATION POMC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:VERCELES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:925-326-8471
Mailing Address - Street 1:155 SAINT GERMAIN LN
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-1135
Mailing Address - Country:US
Mailing Address - Phone:925-326-8471
Mailing Address - Fax:
Practice Address - Street 1:411 30TH ST STE 314
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3312
Practice Address - Country:US
Practice Address - Phone:925-326-8471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-24
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty