Healthcare Provider Details

I. General information

NPI: 1992991418
Provider Name (Legal Business Name): HIEU NHU NGUYEN BA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BRISTOL ST STE 204
COSTA MESA CA
92626-5981
US

IV. Provider business mailing address

2900 BRISTOL ST STE J204
COSTA MESA CA
92626-7920
US

V. Phone/Fax

Practice location:
  • Phone: 714-244-9630
  • Fax:
Mailing address:
  • Phone: 714-244-9630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28147
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: