Healthcare Provider Details

I. General information

NPI: 1841683406
Provider Name (Legal Business Name): KO GENG LIUO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2015
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N MAIN ST #650
SANTA ANA CA
92701-3640
US

IV. Provider business mailing address

35 FIELD #650
IRVINE CA
92620-3345
US

V. Phone/Fax

Practice location:
  • Phone: 714-824-8140
  • Fax:
Mailing address:
  • Phone: 949-981-4515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95001948
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: