Healthcare Provider Details

I. General information

NPI: 1346300191
Provider Name (Legal Business Name): VICKY NINH MAI D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4244 RIVERWALK PKWY STE 150
RIVERSIDE CA
92505-3373
US

IV. Provider business mailing address

4310 ORANGE ST
RIVERSIDE CA
92501-3829
US

V. Phone/Fax

Practice location:
  • Phone: 951-781-6335
  • Fax: 951-781-6365
Mailing address:
  • Phone: 951-781-6335
  • Fax: 951-208-7244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A7549
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A7549
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: