Healthcare Provider Details

I. General information

NPI: 1366866246
Provider Name (Legal Business Name): HEALTHSOURCE MEDICAL NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2014
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11190 WARNER AVE STE 302
FOUNTAIN VALLEY CA
92708-4047
US

IV. Provider business mailing address

417 W ALLEN AVE STE 18
SAN DIMAS CA
91773-4709
US

V. Phone/Fax

Practice location:
  • Phone: 714-241-8000
  • Fax: 714-241-8003
Mailing address:
  • Phone: 909-971-9334
  • Fax: 909-575-3573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: ARNOLD SANVICENTE
Title or Position: PRESIDENT
Credential:
Phone: 909-971-9334