=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922090372
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENTRUST MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2005
-----------------------------------------------------
Last Update Date | 10/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1140 W LA VETA AVE STE. 520
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92868-4225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-543-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5971
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92863-5971
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-571-5000
-----------------------------------------------------
Fax | 714-571-5055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | ROBERT DEL JUNCO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 714-543-2000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------