Healthcare Provider Details

I. General information

NPI: 1427993070
Provider Name (Legal Business Name): TIEV MEDICAL AESTHETICS, A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E 17TH ST STE 200
COSTA MESA CA
92627-7326
US

IV. Provider business mailing address

230 E 17TH ST STE 200
COSTA MESA CA
92627-7326
US

V. Phone/Fax

Practice location:
  • Phone: 714-340-7861
  • Fax:
Mailing address:
  • Phone: 714-340-7861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: CASEY GOODMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 714-261-6540