Provider Demographics
NPI:1356738769
Name:METABOLIC MEDICINE & FITNESS CENTER
Entity type:Organization
Organization Name:METABOLIC MEDICINE & FITNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICA DOCTOR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:H
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-541-4343
Mailing Address - Street 1:17542 17TH ST
Mailing Address - Street 2:SUITE 410
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-1959
Mailing Address - Country:US
Mailing Address - Phone:714-541-4343
Mailing Address - Fax:714-835-9550
Practice Address - Street 1:17542 17TH ST
Practice Address - Street 2:SUITE 410
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1959
Practice Address - Country:US
Practice Address - Phone:714-541-4343
Practice Address - Fax:714-835-9550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78428B305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX I.D. NUMBER