Provider Demographics
NPI:1548374937
Name:PROCARE HEALTH CLINIC
Entity type:Organization
Organization Name:PROCARE HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SON
Authorized Official - Middle Name:LAM
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, LAC
Authorized Official - Phone:310-612-3975
Mailing Address - Street 1:16563 MOUNT SHERROD CIR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-2341
Mailing Address - Country:US
Mailing Address - Phone:310-612-3975
Mailing Address - Fax:310-548-5050
Practice Address - Street 1:643 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-2523
Practice Address - Country:US
Practice Address - Phone:310-548-5984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC9007171100000X
CADC27827111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U87172Medicare UPIN