Healthcare Provider Details

I. General information

NPI: 1255608907
Provider Name (Legal Business Name): GIGI KROLL MCCONNAUGHEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2011
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 NEWPORT CENTER DR 265
NEWPORT BEACH CA
92660-6972
US

IV. Provider business mailing address

180 NEWPORT CENTER DR 265
NEWPORT BEACH CA
92660-6972
US

V. Phone/Fax

Practice location:
  • Phone: 949-706-0181
  • Fax:
Mailing address:
  • Phone: 949-706-0181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA67963
License Number StateCA

VIII. Authorized Official

Name: DR. GIGI KROLL
Title or Position: OWNER
Credential: MD
Phone: 949-706-0181