Healthcare Provider Details

I. General information

NPI: 1265986145
Provider Name (Legal Business Name): OC NEUROLOGY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17822 BEACH BLVD # 374
HUNTINGTON BEACH CA
92647-7101
US

IV. Provider business mailing address

139 VIA ATHENA
ALISO VIEJO CA
92656-1612
US

V. Phone/Fax

Practice location:
  • Phone: 714-848-3333
  • Fax: 714-848-3301
Mailing address:
  • Phone: 949-837-7322
  • Fax: 714-848-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA73709
License Number StateCA

VIII. Authorized Official

Name: DR. NASER M ELBALALESY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 949-837-7322