Healthcare Provider Details

I. General information

NPI: 1588056014
Provider Name (Legal Business Name): SIP DC CA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 ANTON BLVD STE 1100
COSTA MESA CA
92626-7100
US

IV. Provider business mailing address

600 ANTON BLVD STE 1100
COSTA MESA CA
92626-7100
US

V. Phone/Fax

Practice location:
  • Phone: 800-388-3906
  • Fax:
Mailing address:
  • Phone: 800-388-3906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GLENN FORTICH
Title or Position: REVENUE CYCLE MANAGEMENT DIRECTOR
Credential:
Phone: 626-893-9730