Provider Demographics
NPI:1194068775
Name:CENTER FOR COMPREHENSIVE CARE & DIAGNOSIS OF INHERITED BLOOD DISOR
Entity type:Organization
Organization Name:CENTER FOR COMPREHENSIVE CARE & DIAGNOSIS OF INHERITED BLOOD DISOR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, CHC
Authorized Official - Phone:949-748-7546
Mailing Address - Street 1:18011 SKY PARK CIR
Mailing Address - Street 2:SUITE N
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18011 SKY PARK CIR
Practice Address - Street 2:SUITE N
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6517
Practice Address - Country:US
Practice Address - Phone:949-748-7521
Practice Address - Fax:949-748-7615
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE CENTER FOR COMPREHENSIVE CARE & DIAGNOSIS OF INHERITED BLOOD DISOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-01
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY5039863336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGI480AOtherMEDICARE B