Healthcare Provider Details

I. General information

NPI: 1134586126
Provider Name (Legal Business Name): KIET LOC APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24012 CALLE DE LA PLATA SUITE 150
LAGUNA HILLS CA
92653-3621
US

IV. Provider business mailing address

24012 CALLE DE LA PLATA SUITE 150
LAGUNA HILLS CA
92653-3621
US

V. Phone/Fax

Practice location:
  • Phone: 949-837-1130
  • Fax: 949-581-9189
Mailing address:
  • Phone: 949-837-1130
  • Fax: 949-581-9189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberA119338
License Number StateCA

VIII. Authorized Official

Name: KIET MINH LOC
Title or Position: PRESIDENT
Credential: MD
Phone: 949-837-1130