Healthcare Provider Details

I. General information

NPI: 1659887818
Provider Name (Legal Business Name): SHAUNA LAND BC-HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2017
Last Update Date: 12/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19742 MACARTHUR BLVD STE 210
IRVINE CA
92612-2410
US

IV. Provider business mailing address

2618 SAN MIGUEL DR # 490
NEWPORT BEACH CA
92660-5437
US

V. Phone/Fax

Practice location:
  • Phone: 949-462-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2621
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: