=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396729356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOMEN'S MEDICAL CORP OF HUNTINGTON BEACH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2005
-----------------------------------------------------
Last Update Date | 01/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9940 TALBERT AVE SUITE 303
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-5153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-378-5606
-----------------------------------------------------
Fax | 714-378-5621
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9940 TALBERT AVE SUITE 303
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-5153
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-378-5606
-----------------------------------------------------
Fax | 714-378-5621
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | DR. BEVERLY A SANSONE
-----------------------------------------------------
Credential | MEDICAL DOCTOR
-----------------------------------------------------
Telephone | 714-378-5606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | G53820
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------