1285890624 NPI number — PROVIDENCE MEDICAL FOUNDATION

Table of content: (NPI 1285890624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285890624 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:
1285890624
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:
1514 VALLEY VISTA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DIAMOND BAR
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91765-3929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-860-1144
Provider Business Practice Location Address Fax Number:
909-860-8307
Provider Enumeration Date:
08/05/2008

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: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CG4895 . This is a "RAILROAD MEDICARE PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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