1871607762 NPI number — PROVIDENCE MEDICAL FOUNDATION

Table of content: (NPI 1871607762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871607762 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:
1871607762
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2025
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:
714-449-4841
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
955 W IMPERIAL HWY STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92821-3814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-449-4900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2006

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: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X , with the licence number: 091052001 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0062058 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: LAB76828F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0062050 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0062051 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0062053 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0062056 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0062059 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0062057 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR006205A , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0062054 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0062055 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0062052 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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