Basic Information
| Provider Information | |||||||||
| NPI: | 1215434790 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORANGE COAST FYZICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53970 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926193970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497150500 | ||||||||
| FaxNumber: | 9497150504 | ||||||||
| Practice Location | |||||||||
| Address1: | 24361 EL TORO RD STE 140 | ||||||||
| Address2: | |||||||||
| City: | LAGUNA WOODS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926378898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9497150500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2018 | ||||||||
| LastUpdateDate: | 04/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | PETTIS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9497150500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ORANGE COAST HEAD AND NECK SURGERY | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.