Provider Demographics
NPI:1891176350
Name:NU LIFE MEDICAL GROUP
Entity Type:Organization
Organization Name:NU LIFE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HESSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:EFTEKHARI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:619-957-4726
Mailing Address - Street 1:31371 RANCHO VIEJO RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-1848
Mailing Address - Country:US
Mailing Address - Phone:949-565-0444
Mailing Address - Fax:
Practice Address - Street 1:31371 RANCHO VIEJO RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1848
Practice Address - Country:US
Practice Address - Phone:949-565-0444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-10
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9311103K00000X, 207LA0401X, 207LP2900X, 207QA0401X, 208D00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty