Basic Information
| Provider Information | |||||||||
| NPI: | 1285890624 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST JOSEPH HERITAGE HEALTHCARE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 W CENTER STREET PROMENADE STE 300 | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928053960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144494800 | ||||||||
| FaxNumber: | 7144494956 | ||||||||
| Practice Location | |||||||||
| Address1: | 1514 VALLEY VISTA DR | ||||||||
| Address2: | |||||||||
| City: | DIAMOND BAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917653929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098601144 | ||||||||
| FaxNumber: | 9098608307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2008 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUPLECHAN | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7143477790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
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 | CG4895 | 01 | CA | RAILROAD MEDICARE PROVIDER NUMBER | OTHER |