Healthcare Provider Details

I. General information

NPI: 1043331614
Provider Name (Legal Business Name): PROSPECT PROFESSIONAL CARE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 02/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 E 17TH ST SUITE 200
SANTA ANA CA
92705-8626
US

IV. Provider business mailing address

1920 E 17TH ST SUITE 200
SANTA ANA CA
92705-8626
US

V. Phone/Fax

Practice location:
  • Phone: 714-796-5900
  • Fax:
Mailing address:
  • Phone: 714-796-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: LILY KAM
Title or Position: CFO
Credential:
Phone: 714-796-5900