Healthcare Provider Details

I. General information

NPI: 1134246317
Provider Name (Legal Business Name): CANYON PACIFIC OB GYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 04/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16300 SAND CANYON AVE 805
IRVINE CA
92618-3711
US

IV. Provider business mailing address

16300 SAND CANYON AVE 805
IRVINE CA
92618-3711
US

V. Phone/Fax

Practice location:
  • Phone: 949-753-0601
  • Fax:
Mailing address:
  • Phone: 949-753-0601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberG71549
License Number StateCA

VIII. Authorized Official

Name: BRUCE HAGADORN
Title or Position: OWNER
Credential: M.D.
Phone: 949-753-0601