=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073692406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEDUC MEDICAL GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2006
-----------------------------------------------------
Last Update Date | 08/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11160 WARNER AVE SUITE 101
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-4010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-540-0105
-----------------------------------------------------
Fax | 714-540-6727
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11160 WARNER AVE SUITE 101
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-4010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-540-0105
-----------------------------------------------------
Fax | 714-540-6727
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | STUART CHUNG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-540-0105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207SG0201X
-----------------------------------------------------
Taxonomy Name | Clinical Genetics (M.D.) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------