1205131950 NPI number — PROVIDENCE MEDICAL FOUNDATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205131950 NPI number — PROVIDENCE MEDICAL FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE MEDICAL FOUNDATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205131950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 W CENTER STREET PROMENADE STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANAHEIM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92805-3960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-449-4800
Provider Business Mailing Address Fax Number:
714-449-4956

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 TRANCAS ST
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
NAPA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94558-2900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-251-1850
Provider Business Practice Location Address Fax Number:
707-226-1502
Provider Enumeration Date:
01/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DUPLECHAN
Authorized Official First Name:
JILL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF ADMINISTRATIVE OFFICER
Authorized Official Telephone Number:
714-347-7790

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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