1St Industrial Medical Group

Primary specialty

PodiatristTaxonomy code 213E00000X

Legal business name

1ST INDUSTRIAL MEDICAL GROUP

Practice address

1234 W Chapman Ave
Suite 204
Orange, CA 92868-2862

Phone

(714) 289-4693

Fax

(714) 289-4698

NPI assigned

Oct 23, 2007

Last updated

Jun 24, 2008By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mark W BennallackNPI 1699842385

Title

Co Owner

Phone

(714) 289-4693

Specialties & licenses 8

Addresses

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Mark William Bennallack, D.C.

  • Chiropractor
  • Orange, CA
  • NPI 1699842385
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1193097600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1214265600000",
    "number": "1689863995",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1234 W CHAPMAN AVE",
            "address_2": "SUITE # 204",
            "city": "ORANGE",
            "state": "CA",
            "postal_code": "928682862",
            "telephone_number": "714-289-4693",
            "fax_number": "714-289-4698"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1234 W CHAPMAN AVE",
            "address_2": "SUITE 204",
            "city": "ORANGE",
            "state": "CA",
            "postal_code": "928682862",
            "telephone_number": "714-289-4693",
            "fax_number": "714-289-4698"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "1ST INDUSTRIAL MEDICAL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-10-23",
        "last_updated": "2008-06-24",
        "status": "A",
        "authorized_official_last_name": "BENNALLACK",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "CO OWNER",
        "authorized_official_telephone_number": "714-289-4693"
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "",
            "desc": "Chiropractor",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207LP2900X",
            "taxonomy_group": "",
            "desc": "Anesthesiology, Pain Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207XX0004X",
            "taxonomy_group": "",
            "desc": "Orthopaedic Surgery, Foot and Ankle Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208100000X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "2086S0122X",
            "taxonomy_group": "",
            "desc": "Surgery, Plastic and Reconstructive Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208G00000X",
            "taxonomy_group": "",
            "desc": "Thoracic Surgery (Cardiothoracic Vascular Surgery)",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "213E00000X",
            "taxonomy_group": "",
            "desc": "Podiatrist",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Podiatrist in Orange, CA
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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 24, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.