# GLENDALE REJUVENATION MEDICAL GROUP

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Glendale Rejuvenation Medical Group
- **Organization subpart:** No

## Provider details

- **NPI number:** 1073960407
- **Authorized official:** MR. EDDIE SANTIAGO MANAGER (MANAGER)
- **Authorized official phone:** (818) 610-9360

## Contact information

- **Practice address:** 1703 N AVALON BLVD, WILMINGTON, CA 90744-1432
- **Practice address phone:** (310) 233-9355
- **Practice address fax:** (310) 233-2545
- **Mailing address:** 1703 N AVALON BLVD, WILMINGTON, CA 90744-1432
- **Mailing address phone:** (818) 518-5980
- **Mailing address fax:** (818) 551-0466

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 104100000X | Social Worker | — | — | — |
| 111NN1001X | Nutrition Chiropractor | — | — | — |
| 133V00000X | Registered Dietitian | — | — | — |
| 207K00000X | Allergy & Immunology Physician | — | — | — |
| 207QB0002X | Obesity Medicine (Family Medicine) Physician | — | — | Yes |
| 2083S0010X | Sports Medicine (Preventive Medicine) Physician | — | — | — |
| 208D00000X | General Practice Physician | — | — | — |
| 363A00000X | Physician Assistant | — | — | — |

## Other

- **Enumeration date:** 05/16/2016
- **Last updated:** 12/21/2021