Healthcare Provider Details

I. General information

NPI: 1619722964
Provider Name (Legal Business Name): BAO QUOC HOANG OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2024
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4441 E PALM AVE
ORANGE CA
92869-2923
US

IV. Provider business mailing address

4441 E PALM AVE
ORANGE CA
92869-2923
US

V. Phone/Fax

Practice location:
  • Phone: 714-467-5297
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number19273
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: