Provider Demographics
NPI:1811006869
Name:LA MAGNOLIA MEDICAL GROUP
Entity Type:Organization
Organization Name:LA MAGNOLIA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YENCHI
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN PHUC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-894-3103
Mailing Address - Street 1:14571 MAGNOLIA ST. #210
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683
Mailing Address - Country:US
Mailing Address - Phone:714-894-3103
Mailing Address - Fax:714-894-6264
Practice Address - Street 1:14571 MAGNOLIA ST. #210
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683
Practice Address - Country:US
Practice Address - Phone:714-894-3103
Practice Address - Fax:714-894-6264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40020208000000X
CAG63064208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0093500Medicaid