Healthcare Provider Details

I. General information

NPI: 1578652418
Provider Name (Legal Business Name): PAUL D MCKINLEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12556 VALLEY VIEW STREET
GARDEN GROVE CA
92845
US

IV. Provider business mailing address

5638 CAMPO WALK
LONG BEACH CA
90803
US

V. Phone/Fax

Practice location:
  • Phone: 714-897-9355
  • Fax: 714-897-5117
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A7899
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: