Healthcare Provider Details

I. General information

NPI: 1639547706
Provider Name (Legal Business Name): IRVINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2015
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3972 BARRANCA PKWY STE J216
IRVINE CA
92606-1204
US

IV. Provider business mailing address

PO BOX 17208
IRVINE CA
92623-7208
US

V. Phone/Fax

Practice location:
  • Phone: 310-748-7712
  • Fax:
Mailing address:
  • Phone: 310-748-7712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG66853
License Number StateCA

VIII. Authorized Official

Name: DAVID CHENG
Title or Position: SECRETARY
Credential:
Phone: 310-748-7712