Provider Demographics
NPI:1922405877
Name:HARBOR MEDICAL CLINIC AND WELLNESS CENTER,INC.
Entity Type:Organization
Organization Name:HARBOR MEDICAL CLINIC AND WELLNESS CENTER,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRHASHEMI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:949-632-5244
Mailing Address - Street 1:3334 E COAST HWY
Mailing Address - Street 2:SUITE 522
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-2328
Mailing Address - Country:US
Mailing Address - Phone:949-632-5244
Mailing Address - Fax:949-873-2065
Practice Address - Street 1:33 CREEK RD BLDG C2ND
Practice Address - Street 2:SUITE 310
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4791
Practice Address - Country:US
Practice Address - Phone:949-632-5244
Practice Address - Fax:949-873-2065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7098207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH12425Medicare UPIN