MEDICARE: ADVANCED CARE MEDICAL INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1821607789
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED CARE MEDICAL INC

Provider Business Mailing Address
First Line	:	400 NEWPORT CENTER DR STE 301
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-7604
Country	:	US
Telephone Number	:	951-640-7822
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 NEWPORT CENTER DR STE 301
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-7604
Country	:	US
Telephone Number	:	949-644-1300
Fax Number	:	949-644-1306

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LUTHER MANGOBA
Credential	:	MD
Telephone Number	:	951-640-7822

Provider Enumeration Date	:	07/27/2020
Last Update Date	:	07/27/2020

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