Basic Information
| Provider Information | |||||||||
| NPI: | 1093945412 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MISSION HOSPITAL REGIONAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROVIDENCE MISSION HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 31872 COAST HWY | ||||||||
| Address2: | |||||||||
| City: | LAGUNA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926516773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493641400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 31872 COAST HWY | ||||||||
| Address2: | |||||||||
| City: | LAGUNA BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926516773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493641400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2009 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY FOR ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MISSION HOSPITAL REGIONAL MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 060000146 | CA | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 05S567 | 01 | CA | MEDICARE PROVIDER NUMBER | OTHER |