Basic Information
| Provider Information | |||||||||
| NPI: | 1700261443 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARECONNECT MEDICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3090 BRISTOL ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926263061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887899585 | ||||||||
| FaxNumber: | 5628034500 | ||||||||
| Practice Location | |||||||||
| Address1: | 3090 BRISTOL ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926263061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887899585 | ||||||||
| FaxNumber: | 5628034500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2015 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | MLOT | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8887899585 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.