Provider Demographics
NPI:1134586126
Name:KIET LOC APC
Entity type:Organization
Organization Name:KIET LOC APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIET
Authorized Official - Middle Name:MINH
Authorized Official - Last Name:LOC
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-837-1130
Mailing Address - Street 1:24012 CALLE DE LA PLATA
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3621
Mailing Address - Country:US
Mailing Address - Phone:949-837-1130
Mailing Address - Fax:949-581-9189
Practice Address - Street 1:24012 CALLE DE LA PLATA
Practice Address - Street 2:SUITE 150
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3621
Practice Address - Country:US
Practice Address - Phone:949-837-1130
Practice Address - Fax:949-581-9189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1193382084B0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & NeuropsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB205862Medicare PIN