Healthcare Provider Details

I. General information

NPI: 1093626590
Provider Name (Legal Business Name): JEFFREY BURKHOLDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6640 ALTON PKWY
IRVINE CA
92618-3734
US

IV. Provider business mailing address

410 SHEA LN
LONG BEACH CA
90803-2041
US

V. Phone/Fax

Practice location:
  • Phone: 949-932-2863
  • Fax:
Mailing address:
  • Phone: 949-932-2863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number784263
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: