Healthcare Provider Details

I. General information

NPI: 1619829454
Provider Name (Legal Business Name): VITA IPA MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2026
Last Update Date: 02/12/2026
Certification Date: 02/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 N HARBOR BLVD STE 219
FULLERTON CA
92832-1901
US

IV. Provider business mailing address

2271 W MALVERN AVE # 1186
FULLERTON CA
92833-2106
US

V. Phone/Fax

Practice location:
  • Phone: 213-296-0352
  • Fax: 213-277-8747
Mailing address:
  • Phone: 213-296-0352
  • Fax: 213-277-8747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: PHILLIP LIM
Title or Position: PRESIDENT
Credential: DO
Phone: 213-296-0352