1669067963 NPI number — SOUTHLAND ORTHO SOLUTIONS, LLC

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 1669067963 NPI number — SOUTHLAND ORTHO SOLUTIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHLAND ORTHO SOLUTIONS, LLC
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:
1669067963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27702 CROWN VALLEY PARKWAY
Provider Second Line Business Mailing Address:
SUITE D-4 #230
Provider Business Mailing Address City Name:
LADERA RANCH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92694
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-433-5115
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23362 PERALTA DR STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAGUNA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92653-1711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-328-9622
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2021

Additional Information

Authorized Official

Authorized Official Last Name:
FORTUN
Authorized Official First Name:
FRED
Authorized Official Middle Name:
Authorized Official Title or Position:
PRINCIPAL
Authorized Official Telephone Number:
949-433-5115

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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