Provider Demographics
NPI:1487075693
Name:PREMIERE SPORTS MEDICINE MEDICAL GROUP
Entity type:Organization
Organization Name:PREMIERE SPORTS MEDICINE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NAIM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-322-8777
Mailing Address - Street 1:2255 E MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-6508
Mailing Address - Country:US
Mailing Address - Phone:310-322-8777
Mailing Address - Fax:
Practice Address - Street 1:2255 E MAPLE AVE
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-6508
Practice Address - Country:US
Practice Address - Phone:310-322-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC32082111N00000X
CAAC15268171100000X
CAG80322208100000X
CADC29474111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty