Healthcare Provider Details

I. General information

NPI: 1396055414
Provider Name (Legal Business Name): ADVANCED HEALTHCARE ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17220 NEWHOPE ST 125
FOUNTAIN VALLEY CA
92708-4272
US

IV. Provider business mailing address

17220 NEWHOPE ST 125
FOUNTAIN VALLEY CA
92708-4272
US

V. Phone/Fax

Practice location:
  • Phone: 714-435-0600
  • Fax: 714-960-8007
Mailing address:
  • Phone: 714-435-0600
  • Fax: 714-960-8007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA47792
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG32104
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA37535
License Number StateCA

VIII. Authorized Official

Name: MRS. NELLY BOUTROS
Title or Position: ADMIN
Credential:
Phone: 714-317-3044