Healthcare Provider Details

I. General information

NPI: 1811006869
Provider Name (Legal Business Name): LA MAGNOLIA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14571 MAGNOLIA ST. #210
WESTMINSTER CA
92683
US

IV. Provider business mailing address

14571 MAGNOLIA ST. #210
WESTMINSTER CA
92683
US

V. Phone/Fax

Practice location:
  • Phone: 714-894-3103
  • Fax: 714-894-6264
Mailing address:
  • Phone: 714-894-3103
  • Fax: 714-894-6264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA40020
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG63064
License Number StateCA

VIII. Authorized Official

Name: DR. YENCHI NGUYEN PHUC
Title or Position: PRESIDENT
Credential: MD
Phone: 714-894-3103