Healthcare Provider Details

I. General information

NPI: 1164060406
Provider Name (Legal Business Name): ERA KO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2019
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 THE CITY DR S
ORANGE CA
92868-3305
US

IV. Provider business mailing address

14382 RED HILL AVE APT 10
TUSTIN CA
92780-6266
US

V. Phone/Fax

Practice location:
  • Phone: 949-751-9143
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113498
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: