Basic Information
| Provider Information | |||||||||
| NPI: | 1083031769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REICHERT | ||||||||
| FirstName: | SUNEUN | ||||||||
| MiddleName: | SARAH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KIM | ||||||||
| OtherFirstName: | SUNEUN | ||||||||
| OtherMiddleName: | SARAH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14642 NEWPORT AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927806059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142470300 | ||||||||
| FaxNumber: | 7142591598 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOPE DR | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927820221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142470300 | ||||||||
| FaxNumber: | 7142591598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2014 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 04/15/2019 | ||||||||
| NPIReactivationDate: | 04/24/2019 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 390200000X | PTL1271 | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 19660 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.