MEDICARE: SUSIATI GUNAWAN LVN

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	164X00000X	Licensed Vocational Nurse	VN257822	CA

General Provider Information

NPI Number	:	1598133357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSIATI GUNAWAN LVN

Provider Business Mailing Address
First Line	:	2401 VENIER WAY
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-1441
Country	:	US
Telephone Number	:	714-260-8386
Fax Number	:

Provider Business Practice Location Address
First Line	:	2401 VENIER WAY
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-1441
Country	:	US
Telephone Number	:	714-260-8386
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2015
Last Update Date	:	09/10/2015

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