1891948717 NPI number — ETC CONSULTANTS INC

Table of content: (NPI 1891948717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891948717 NPI number — ETC CONSULTANTS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ETC CONSULTANTS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LORPHEN MEDICAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891948717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 COLOMA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92602-2438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-689-9754
Provider Business Mailing Address Fax Number:
949-313-5078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3151 AIRWAY AVE STE T3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COSTA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92626-4627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-689-9754
Provider Business Practice Location Address Fax Number:
714-545-5748
Provider Enumeration Date:
10/23/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NGUYEN
Authorized Official First Name:
CHARLES TUAN-TU
Authorized Official Middle Name:
SONG
Authorized Official Title or Position:
MEDICAL DIRECTOR/OWNER
Authorized Official Telephone Number:
949-689-9754

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  A69542 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A69542 . This is a "STATE LECENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".