Healthcare Provider Details

I. General information

NPI: 1497262695
Provider Name (Legal Business Name): MEGA WELLNESS CLINIC NURSING PRACTITIONER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 S BREA BLVD
BREA CA
92821-5301
US

IV. Provider business mailing address

432 S BREA BLVD
BREA CA
92821-5301
US

V. Phone/Fax

Practice location:
  • Phone: 714-784-6767
  • Fax: 714-784-6757
Mailing address:
  • Phone: 714-784-6767
  • Fax: 714-784-6757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18049
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA4078
License Number StateCA

VIII. Authorized Official

Name: MRS. AE RAH KANG
Title or Position: NP
Credential: NURSE PRACTITIONER
Phone: 714-784-6767