Healthcare Provider Details

I. General information

NPI: 1639613359
Provider Name (Legal Business Name): PROHEALTH PARTNERS A MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 04/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 BRISTOL ST STE B203
COSTA MESA CA
92626-5948
US

IV. Provider business mailing address

2900 BRISTOL ST # B203B205
COSTA MESA CA
92626-5981
US

V. Phone/Fax

Practice location:
  • Phone: 855-867-5551
  • Fax: 562-594-8557
Mailing address:
  • Phone: 855-867-5551
  • Fax: 949-209-1981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: BARRY STEVEN ALLSWANG
Title or Position: PRESIDENT
Credential: MD
Phone: 562-299-5200