Healthcare Provider Details

I. General information

NPI: 1891176350
Provider Name (Legal Business Name): NU LIFE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31371 RANCHO VIEJO RD STE 104
SAN JUAN CAPISTRANO CA
92675-1848
US

IV. Provider business mailing address

31371 RANCHO VIEJO RD STE 104
SAN JUAN CAPISTRANO CA
92675-1848
US

V. Phone/Fax

Practice location:
  • Phone: 949-565-0444
  • Fax:
Mailing address:
  • Phone: 949-565-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number20A9311
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number20A9311
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number20A9311
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number20A9311
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number20A9311
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A9311
License Number StateCA

VIII. Authorized Official

Name: HESSAM EFTEKHARI
Title or Position: OWNER
Credential: DO
Phone: 619-957-4726