Healthcare Provider Details

I. General information

NPI: 1639611445
Provider Name (Legal Business Name): UNDONO CARE ANAHEIM 1, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2016
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1248 S MAGNOLIA AVE
ANAHEIM CA
92804-5116
US

IV. Provider business mailing address

1248 S MAGNOLIA AVE
ANAHEIM CA
92804-5116
US

V. Phone/Fax

Practice location:
  • Phone: 714-883-9541
  • Fax: 888-568-3105
Mailing address:
  • Phone: 714-883-9541
  • Fax: 888-568-3105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: KIMLIEN TRAN
Title or Position: MANAGER
Credential:
Phone: 858-717-0088