Provider Demographics
NPI:1366834756
Name:PROSPECT FOOTHILL URGENT CARE
Entity Type:Organization
Organization Name:PROSPECT FOOTHILL URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-813-5129
Mailing Address - Street 1:PO BOX 11466
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92711-1466
Mailing Address - Country:US
Mailing Address - Phone:714-522-2891
Mailing Address - Fax:714-903-7801
Practice Address - Street 1:14642 NEWPORT AVE STE 101
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6058
Practice Address - Country:US
Practice Address - Phone:714-522-2891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW GENESIS MEDICAL ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-23
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care