Organization
FULLERTON ORTHOPAEDIC SURGERY MEDICAL GROUP, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KENDALL WAGNER (PRESIDENT)
(714) 879-0050
Entity
Organization
Contact information
Practice address
15039 GOLDENWEST ST, HUNTINGTON BEACH, CA 92647-2710
(714) 893-7400
(714) 893-7022
Mailing address
101 LAGUNA RD STE A, FULLERTON, CA 92835-3635
(714) 879-0050
(714) 879-0249
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
20A9973
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
W1365
MEDICARE
CA
Enumeration date
08/04/2011
Last updated
08/04/2011
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