MEDICARE: PROSPECT FOOTHILL URGENT CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1366834756
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROSPECT FOOTHILL URGENT CARE

Provider Business Mailing Address
First Line	:	PO BOX 11466
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92711-1466
Country	:	US
Telephone Number	:	714-522-2891
Fax Number	:	714-903-7801

Provider Business Practice Location Address
First Line	:	14642 NEWPORT AVE STE 101
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92780-6058
Country	:	US
Telephone Number	:	714-522-2891
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MITCHELL W LEW
Credential	:	MD
Telephone Number	:	714-813-5129

Provider Enumeration Date	:	02/23/2015
Last Update Date	:	03/26/2015

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