Healthcare Provider Details

I. General information

NPI: 1396675880
Provider Name (Legal Business Name): JUSTINE LO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 S COAST DR STE 225
COSTA MESA CA
92626-7757
US

IV. Provider business mailing address

13967 WHITEROCK DR
LA MIRADA CA
90638-3822
US

V. Phone/Fax

Practice location:
  • Phone: 949-743-1457
  • Fax:
Mailing address:
  • Phone: 209-631-9243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: