Provider Demographics
NPI:1720645104
Name:OCEAN LIFE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:OCEAN LIFE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:ORIGEL
Authorized Official - Suffix:JR
Authorized Official - Credentials:NP
Authorized Official - Phone:661-289-1154
Mailing Address - Street 1:18069 W TERRA VERDE PLACE
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91387-1830
Mailing Address - Country:US
Mailing Address - Phone:661-360-7523
Mailing Address - Fax:661-424-7990
Practice Address - Street 1:18069 W TERRA VERDE PLACE
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91387-1830
Practice Address - Country:US
Practice Address - Phone:661-360-7523
Practice Address - Fax:661-424-7900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty