Healthcare Provider Details

I. General information

NPI: 1710271663
Provider Name (Legal Business Name): LILLY KAO, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 06/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14351 RED HILL AVE SUITE C
TUSTIN CA
92780-6271
US

IV. Provider business mailing address

28 MONARCH BAY PLZ SUITE N
DANA POINT CA
92629-3460
US

V. Phone/Fax

Practice location:
  • Phone: 714-838-5562
  • Fax: 714-838-5560
Mailing address:
  • Phone: 949-489-5564
  • Fax: 949-493-9350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC53602
License Number StateCA

VIII. Authorized Official

Name: LORI R GRANESE
Title or Position: COO
Credential:
Phone: 949-489-5564