Basic Information
| Provider Information | |||||||||
| NPI: | 1093947251 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THC - ORANGE COUNTY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1940 EL CAJON BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921041005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195434500 | ||||||||
| FaxNumber: | 6192942979 | ||||||||
| Practice Location | |||||||||
| Address1: | 1940 EL CAJON BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195434500 | ||||||||
| FaxNumber: | 6192942979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2009 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | DARVISH | ||||||||
| AuthorizedOfficialFirstName: | MOSTAFA | ||||||||
| AuthorizedOfficialMiddleName: | ADAM | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7148934541 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | ZZT30220I | 05 | CA | MEDICAID | 052035 | 01 | CA | BLUE CROSS | OTHER | ZZT40220I | 01 | CA | HEALTH NET | OTHER |