Healthcare Provider Details

I. General information

NPI: 1942321567
Provider Name (Legal Business Name): OBRIA MEDICAL CLINICS OF SOUTHERN CALIFORNIA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8352 COMMONWEALTH AVE
BUENA PARK CA
90621-2526
US

IV. Provider business mailing address

1200 MAIN ST SUITE C
IRVINE CA
92614-6749
US

V. Phone/Fax

Practice location:
  • Phone: 949-364-3928
  • Fax: 657-239-0081
Mailing address:
  • Phone: 949-916-8868
  • Fax: 949-273-5041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number550000145
License Number StateCA

VIII. Authorized Official

Name: MAURICIO LEONE
Title or Position: CHIEF OPERATIONS OFFICER
Credential: MPA
Phone: 949-273-6217