Healthcare Provider Details

I. General information

NPI: 1356731962
Provider Name (Legal Business Name): UC IRVINE HEALTH SPECIALTY CLINIC- TUSTIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 10/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 IRVINE BLVD
TUSTIN CA
92780-3804
US

IV. Provider business mailing address

PO BOX 54509
LOS ANGELES CA
90054-0509
US

V. Phone/Fax

Practice location:
  • Phone: 714-838-8878
  • Fax: 714-838-8988
Mailing address:
  • Phone: 714-456-6585
  • Fax: 714-456-8101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROGER L. CRUMLEY
Title or Position: INTERIM PRESIDENT
Credential: MD
Phone: 714-456-2986