1639523905 NPI number — SOUTH COAST ORTHOPEDICS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639523905 NPI number — SOUTH COAST ORTHOPEDICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH COAST ORTHOPEDICS
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:
Provider Other Organization Name Type Code:
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:
1639523905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18102 IRVINE BLVD
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92780-3402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-508-4123
Provider Business Mailing Address Fax Number:
714-508-4134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 HEMLOCK WAY
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92707-3650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-508-4123
Provider Business Practice Location Address Fax Number:
714-508-4134
Provider Enumeration Date:
04/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
AVAL
Authorized Official First Name:
SOHEIL
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
714-508-4123

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A67928 , 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)





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