Healthcare Provider Details

I. General information

NPI: 1225063340
Provider Name (Legal Business Name): CENTRAL COUNTY CHEST MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11180 WARNER AVE STE 253
FOUNTAIN VALLEY CA
92708-7515
US

IV. Provider business mailing address

11180 WARNER AVE STE 253
FOUNTAIN VALLEY CA
92708-7515
US

V. Phone/Fax

Practice location:
  • Phone: 714-979-2825
  • Fax: 714-979-2862
Mailing address:
  • Phone: 714-979-2825
  • Fax: 714-979-2862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA42385
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberA43693
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA43693
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA42385
License Number StateCA

VIII. Authorized Official

Name: MS. MARY AGUIRRE
Title or Position: OFFICE MANAGER
Credential:
Phone: 714-979-2825