Provider Demographics
NPI:1760594451
Name:SOUTHERN HEART CLINIC, INC.
Entity Type:Organization
Organization Name:SOUTHERN HEART CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:TIEN
Authorized Official - Last Name:TRUONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-432-1212
Mailing Address - Street 1:11100 WARNER AVE STE 152
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7510
Mailing Address - Country:US
Mailing Address - Phone:714-432-1212
Mailing Address - Fax:714-432-1213
Practice Address - Street 1:11100 WARNER AVE STE 152
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7510
Practice Address - Country:US
Practice Address - Phone:714-432-1212
Practice Address - Fax:714-432-1213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA053527207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0032BWMedicare ID - Type Unspecified
TXG54838Medicare UPIN