Healthcare Provider Details

I. General information

NPI: 1568736304
Provider Name (Legal Business Name): SOUTH COAST SPINE AND WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2012
Last Update Date: 02/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26841 CALLE HERMOSA SUITE A
CAPISTRANO BEACH CA
92624-1674
US

IV. Provider business mailing address

26841 CALLE HERMOSA SUITE A
CAPISTRANO BEACH CA
92624-1674
US

V. Phone/Fax

Practice location:
  • Phone: 949-488-9600
  • Fax: 949-488-9601
Mailing address:
  • Phone: 949-488-9600
  • Fax: 949-488-9601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. VICTORIA CUPIC
Title or Position: VICE PRESIDENT
Credential: M.D.
Phone: 949-488-9600