Healthcare Provider Details

I. General information

NPI: 1083123129
Provider Name (Legal Business Name): KASRA ABOLHOSSEINI AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 09/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12791 NEWPORT AVE STE 101
TUSTIN CA
92780-2785
US

IV. Provider business mailing address

30642 MIRANDELA LN
LAGUNA NIGUEL CA
92677-2347
US

V. Phone/Fax

Practice location:
  • Phone: 714-731-6549
  • Fax: 714-730-5372
Mailing address:
  • Phone: 949-579-0957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU3255
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: