Healthcare Provider Details

I. General information

NPI: 1710284427
Provider Name (Legal Business Name): HOA VU MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 02/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N D ST #320
SAN BERNARDINO CA
92401-1545
US

IV. Provider business mailing address

PO BOX 9057
REDLANDS CA
92375-2257
US

V. Phone/Fax

Practice location:
  • Phone: 909-381-3900
  • Fax:
Mailing address:
  • Phone: 951-738-0968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA62459
License Number StateCA

VIII. Authorized Official

Name: MS. KIMBERLY DIANE SWANSON
Title or Position: ACCOUNT MANAGER
Credential:
Phone: 951-738-0968