Provider Demographics
NPI:1710458245
Name:ENLIGHTENED HEALTHCARE ALLIANCE MEDICAL CORPORATION
Entity Type:Organization
Organization Name:ENLIGHTENED HEALTHCARE ALLIANCE MEDICAL CORPORATION
Other - Org Name:GOOD MEDICINE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIE
Authorized Official - Middle Name:KHANH
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:833-466-6363
Mailing Address - Street 1:PO BOX 231366
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92023-1366
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:662 ENCINITAS BLVD STE 220
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-6791
Practice Address - Country:US
Practice Address - Phone:833-446-6363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-10
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1710458245Medicaid
CAA64699OtherMEDICAL LICENSE