Healthcare Provider Details

I. General information

NPI: 1811923303
Provider Name (Legal Business Name): 12072 TRASK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12072 TRASK AVE
GARDEN GROVE CA
92843-3821
US

IV. Provider business mailing address

12072 TRASK AVE
GARDEN GROVE CA
92843-3821
US

V. Phone/Fax

Practice location:
  • Phone: 714-534-1942
  • Fax: 714-534-0967
Mailing address:
  • Phone: 714-534-1942
  • Fax: 714-534-0967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number38640058
License Number StateCA

VIII. Authorized Official

Name: MR. MARK URANGA
Title or Position: ASSISTANT ADMINISTRATOR
Credential:
Phone: 714-534-1943