Healthcare Provider Details

I. General information

NPI: 1720500408
Provider Name (Legal Business Name): ORANGE COUNTY MISSION CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13422 NEWPORT AVE STE G
TUSTIN CA
92780-3746
US

IV. Provider business mailing address

13422 NEWPORT AVE STE G
TUSTIN CA
92780-3746
US

V. Phone/Fax

Practice location:
  • Phone: 714-731-7772
  • Fax: 714-884-3644
Mailing address:
  • Phone: 714-731-7772
  • Fax: 714-884-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number28104
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number28104
License Number StateCA

VIII. Authorized Official

Name: DR. GREG S KIM
Title or Position: OWNER
Credential: DC
Phone: 714-731-7772