Healthcare Provider Details

I. General information

NPI: 1760464424
Provider Name (Legal Business Name): KOFFORD MEDICAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24582 DEL PRADO STE H
DANA POINT CA
92629-3843
US

IV. Provider business mailing address

24582 DEL PRADO STE H
DANA POINT CA
92629-3843
US

V. Phone/Fax

Practice location:
  • Phone: 949-493-7777
  • Fax: 949-388-7264
Mailing address:
  • Phone: 949-493-7777
  • Fax: 949-388-7264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberA70574
License Number StateCA

VIII. Authorized Official

Name: DR. MARK W. KOFFORD
Title or Position: OWNER
Credential: MD, PHD
Phone: 949-493-7777