Healthcare Provider Details

I. General information

NPI: 1366834756
Provider Name (Legal Business Name): PROSPECT FOOTHILL URGENT CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14642 NEWPORT AVE STE 101
TUSTIN CA
92780-6058
US

IV. Provider business mailing address

PO BOX 11466
SANTA ANA CA
92711-1466
US

V. Phone/Fax

Practice location:
  • Phone: 714-522-2891
  • Fax:
Mailing address:
  • Phone: 714-522-2891
  • Fax: 714-903-7801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MITCHELL W LEW
Title or Position: OWNER
Credential: MD
Phone: 714-813-5129