Healthcare Provider Details

I. General information

NPI: 1811149677
Provider Name (Legal Business Name): BRUSH ADVISORIES MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N MAIN ST STE 111
SANTA ANA CA
92701
US

IV. Provider business mailing address

PO BOX 1261
SANTA ANA CA
92702
US

V. Phone/Fax

Practice location:
  • Phone: 714-973-2378
  • Fax:
Mailing address:
  • Phone: 714-460-2948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License NumberA37875
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA37875
License Number State

VIII. Authorized Official

Name: MR. KENRICK ANTHONY LICORISH
Title or Position: CEO
Credential: MD
Phone: 714-460-2948