=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801352265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAGUNA VEIN CENTER INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2019
-----------------------------------------------------
Last Update Date | 02/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24902 MOULTON PKWY STE 200
-----------------------------------------------------
City | LAGUNA HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92637-6403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-305-5165
-----------------------------------------------------
Fax | 949-485-6229
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4790 IRVINE BLVD STE 105-141
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92620-1973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-924-9009
-----------------------------------------------------
Fax | 949-485-6229
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN D. BAKER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 877-924-9009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------