=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629317995
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERSONALCARE PHYSICIANS OF IRVINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2013
-----------------------------------------------------
Last Update Date | 11/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 E COAST HWY STE 250
-----------------------------------------------------
City | CORONA DEL MAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92625-1932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-706-3300
-----------------------------------------------------
Fax | 949-706-3301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 E COAST HWY STE 250
-----------------------------------------------------
City | CORONA DEL MAR
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92625-1932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-706-3300
-----------------------------------------------------
Fax | 949-706-3301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFF BARKE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 949-629-2607
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | G72290
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------