Basic Information
| Provider Information | |||||||||
| NPI: | 1306965587 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HURTT FAMILY HEALTH CLINIC INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOPE DRIVE | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927820221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142470300 | ||||||||
| FaxNumber: | 7142591598 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HOPE DRIVE | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927820221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142470300 | ||||||||
| FaxNumber: | 7142591598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | BECKY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7142478044 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | CMM70904F | 05 | CA | MEDICAID |