Healthcare Provider Details

I. General information

NPI: 1013013770
Provider Name (Legal Business Name): SOUTHERN CALIFORNIA COLON AND RECTAL MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23961 CALLE MAGDALENA #231
LAGUNA HILLS CA
92653
US

IV. Provider business mailing address

23961 CALLE MAGDALENA #231
LAGUNA HILLS CA
92653
US

V. Phone/Fax

Practice location:
  • Phone: 949-609-0500
  • Fax: 949-609-0504
Mailing address:
  • Phone: 949-609-0500
  • Fax: 949-609-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberG79692
License Number StateCA

VIII. Authorized Official

Name: GENE L SYN
Title or Position: CEO/PRESIDENT
Credential: MD
Phone: 949-609-0500