Healthcare Provider Details

I. General information

NPI: 1265006258
Provider Name (Legal Business Name): 111 FASHION LANE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 FASHION LN
TUSTIN CA
92780-3306
US

IV. Provider business mailing address

111 FASHION LN
TUSTIN CA
92780-3306
US

V. Phone/Fax

Practice location:
  • Phone: 714-619-8636
  • Fax: 866-646-1488
Mailing address:
  • Phone: 714-619-8636
  • Fax: 866-646-1488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AGNES YEN SINCLAIR
Title or Position: MANAGER
Credential:
Phone: 626-429-9290