Provider Demographics
NPI:1720295744
Name:CONCENTRA MEDICAL CENTER
Entity Type:Organization
Organization Name:CONCENTRA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:MYRON
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:714-522-8051
Mailing Address - Street 1:26 CENTERPOINTE DR
Mailing Address - Street 2:115
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1072
Mailing Address - Country:US
Mailing Address - Phone:714-522-8051
Mailing Address - Fax:714-522-5703
Practice Address - Street 1:26 CENTERPOINTE DR
Practice Address - Street 2:115
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1072
Practice Address - Country:US
Practice Address - Phone:714-522-8051
Practice Address - Fax:714-522-5703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT3551261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine