MEDICARE: KOFFORD MEDICAL CORP.

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	A70574	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760464424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOFFORD MEDICAL CORP.

Provider Business Mailing Address
First Line	:	24582 DEL PRADO
Second Line	:	STE H
City	:	DANA POINT
State	:	CA
Zip	:	92629-3843
Country	:	US
Telephone Number	:	949-493-7777
Fax Number	:	949-388-7264

Provider Business Practice Location Address
First Line	:	24582 DEL PRADO
Second Line	:	STE H
City	:	DANA POINT
State	:	CA
Zip	:	92629-3843
Country	:	US
Telephone Number	:	949-493-7777
Fax Number	:	949-388-7264

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARK W. KOFFORD
Credential	:	MD, PHD
Telephone Number	:	949-493-7777

Provider Enumeration Date	:	11/17/2005
Last Update Date	:	06/25/2010

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Directions to “KOFFORD MEDICAL CORP. ” Practice Location

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