Healthcare Provider Details

I. General information

NPI: 1184044141
Provider Name (Legal Business Name): NONSURGICAL MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 S HARBOR BLVD SUITE B
SANTA ANA CA
92704-7901
US

IV. Provider business mailing address

5626 OBERLIN DR SUITE 110
SAN DIEGO CA
92121-1705
US

V. Phone/Fax

Practice location:
  • Phone: 714-751-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberA52791
License Number StateCA

VIII. Authorized Official

Name: KENNY HEINE
Title or Position: VP OF OPERATIONS
Credential:
Phone: 858-964-1506