Healthcare Provider Details

I. General information

NPI: 1902844103
Provider Name (Legal Business Name): PERSONAL HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 CORPORATE PLAZA DR 110
NEWPORT BEACH CA
92660-7902
US

IV. Provider business mailing address

17 CORPORATE PLAZA DR 110
NEWPORT BEACH CA
92660-7902
US

V. Phone/Fax

Practice location:
  • Phone: 949-706-3300
  • Fax: 949-706-3301
Mailing address:
  • Phone: 949-706-3300
  • Fax: 949-706-3301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA69169
License Number StateCA

VIII. Authorized Official

Name: MARCIA WHALEN
Title or Position: PRESIDENT
Credential: D.O
Phone: 949-650-5353