Healthcare Provider Details

I. General information

NPI: 1134482177
Provider Name (Legal Business Name): LAVINIA K. CHONG, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 AVOCADO AVE SUITE 803
NEWPORT BEACH CA
92660-7720
US

IV. Provider business mailing address

1401 AVOCADO AVE SUITE 803
NEWPORT BEACH CA
92660-7720
US

V. Phone/Fax

Practice location:
  • Phone: 949-644-1400
  • Fax: 949-644-5988
Mailing address:
  • Phone: 949-644-1400
  • Fax: 949-644-5988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberG68371
License Number StateCA

VIII. Authorized Official

Name: DR. LAVINIA KAREN CHONG
Title or Position: CHIEF MEDICAL OFFICER
Credential: M.D.
Phone: 949-644-1400