Healthcare Provider Details

I. General information

NPI: 1699248302
Provider Name (Legal Business Name): OH PHUKET
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 RYLAND ST STE 200A
RENO NV
89502-1643
US

IV. Provider business mailing address

1406 SCOTT DR
NATIONAL CITY CA
91950-1627
US

V. Phone/Fax

Practice location:
  • Phone: 619-865-0445
  • Fax:
Mailing address:
  • Phone: 619-865-0445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code341600000X
TaxonomyAmbulance
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3416A0800X
TaxonomyAir Ambulance
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3416S0300X
TaxonomyWater Ambulance
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JUAN ANTONIO QUIROZ JR.
Title or Position: CEO
Credential:
Phone: 619-865-0445