Healthcare Provider Details

I. General information

NPI: 1447306543
Provider Name (Legal Business Name): LIGHTHOUSE ANESTHESIA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12601 GARDEN GROVE BLVD
GARDEN GROVE CA
92843-1908
US

IV. Provider business mailing address

PO BOX 775
GARDEN GROVE CA
92842-0775
US

V. Phone/Fax

Practice location:
  • Phone: 714-537-5160
  • Fax:
Mailing address:
  • Phone: 714-636-0343
  • Fax: 714-636-0391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG81625
License Number StateCA

VIII. Authorized Official

Name: TAM-NGUYEN THI PHAM
Title or Position: OWNER
Credential: M.D.
Phone: 714-636-0343