Healthcare Provider Details

I. General information

NPI: 1548374937
Provider Name (Legal Business Name): PROCARE HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 W 6TH ST
SAN PEDRO CA
90731-2523
US

IV. Provider business mailing address

16563 MOUNT SHERROD CIR
FOUNTAIN VALLEY CA
92708-2341
US

V. Phone/Fax

Practice location:
  • Phone: 310-548-5984
  • Fax:
Mailing address:
  • Phone: 310-612-3975
  • Fax: 310-548-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC27827
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC9007
License Number StateCA

VIII. Authorized Official

Name: DR. SON LAM NGUYEN
Title or Position: OWNER
Credential: D.C, L.AC
Phone: 310-612-3975