Healthcare Provider Details

I. General information

NPI: 1578017778
Provider Name (Legal Business Name): MESA ADVANTAGE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 HUNTINGTON DR # D
SAN MARINO CA
91108-2640
US

IV. Provider business mailing address

2295 HUNTINGTON DR # D
SAN MARINO CA
91108-2640
US

V. Phone/Fax

Practice location:
  • Phone: 626-656-2370
  • Fax: 626-248-9060
Mailing address:
  • Phone: 626-656-2370
  • Fax: 626-248-9060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberA
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. LAN NHU BICH PHAN
Title or Position: CEO
Credential:
Phone: 818-399-8996