=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770931529
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GORETTI HO TAGHVA, M.D. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2016
-----------------------------------------------------
Last Update Date | 06/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1902 MCCLEAN DR
-----------------------------------------------------
City | NORTH TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-3319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-547-0851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1902 MCCLEAN DR
-----------------------------------------------------
City | NORTH TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-3319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-547-0851
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GORETTI HO TAGHVA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-547-0851
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | A108049
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------