Healthcare Provider Details

I. General information

NPI: 1639691397
Provider Name (Legal Business Name): SARAH APOLLO DT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 ODYSSEY STE 155
IRVINE CA
92618-3194
US

IV. Provider business mailing address

PO BOX 36
DANA POINT CA
92629-0036
US

V. Phone/Fax

Practice location:
  • Phone: 714-202-7909
  • Fax: 866-242-5109
Mailing address:
  • Phone: 714-202-7909
  • Fax: 866-242-5109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number20A6613
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number20A6613
License Number StateCA

VIII. Authorized Official

Name: DEBRA L SANDERSON
Title or Position: CLINIC MANGER
Credential:
Phone: 661-993-8941