Provider Demographics
NPI:1104044288
Name:ST. MARTIN FAMILY MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:ST. MARTIN FAMILY MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-537-3900
Mailing Address - Street 1:12555 GARDEN GROVE BLVD STE 506
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1904
Mailing Address - Country:US
Mailing Address - Phone:714-537-3900
Mailing Address - Fax:714-537-7300
Practice Address - Street 1:12555 GARDEN GROVE BLVD STE 506
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1904
Practice Address - Country:US
Practice Address - Phone:714-537-3900
Practice Address - Fax:714-537-7300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61958305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A061958Medicaid
CAW15494Medicare PIN