Healthcare Provider Details

I. General information

NPI: 1124689989
Provider Name (Legal Business Name): BREASTLINK MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S MAIN ST STE B-100
ORANGE CA
92868-3851
US

IV. Provider business mailing address

1510 COTNER AVE
LOS ANGELES CA
90025-3303
US

V. Phone/Fax

Practice location:
  • Phone: 714-541-0101
  • Fax: 714-541-0450
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: HOWARD GERALD BERGER
Title or Position: PRESIDENT
Credential:
Phone: 310-445-2951