Healthcare Provider Details

I. General information

NPI: 1124123096
Provider Name (Legal Business Name): MISSION CHILDREN'S MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26732 CROWN VALLEY PKWY STE 571
MISSION VIEJO CA
92691-6306
US

IV. Provider business mailing address

26732 CROWN VALLEY PKWY STE 571
MISSION VIEJO CA
92691-6306
US

V. Phone/Fax

Practice location:
  • Phone: 949-364-8700
  • Fax: 949-365-1011
Mailing address:
  • Phone: 949-364-8700
  • Fax: 949-365-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KURT D MILLER
Title or Position: CEO
Credential: MD
Phone: 949-364-8700