Healthcare Provider Details

I. General information

NPI: 1720516628
Provider Name (Legal Business Name): OC TRAUMA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26732 CROWN VALLEY PKWY STE 351
MISSION VIEJO CA
92691-6374
US

IV. Provider business mailing address

26732 CROWN VALLEY PKWY STE 351
MISSION VIEJO CA
92691-6374
US

V. Phone/Fax

Practice location:
  • Phone: 949-364-1007
  • Fax: 949-588-8719
Mailing address:
  • Phone: 949-364-1007
  • Fax: 949-588-8719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM WALLACE
Title or Position: CEO
Credential: MD
Phone: 949-457-7900