Healthcare Provider Details

I. General information

NPI: 1609332394
Provider Name (Legal Business Name): SUNSET SHORELINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 WESTCLIFF DR STE 309
NEWPORT BEACH CA
92660-5519
US

IV. Provider business mailing address

1501 WESTCLIFF DR STE 309
NEWPORT BEACH CA
92660-5519
US

V. Phone/Fax

Practice location:
  • Phone: 714-698-4500
  • Fax:
Mailing address:
  • Phone: 714-698-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH KILLEBREW
Title or Position: MEMBER
Credential:
Phone: 714-698-4500