Basic Information
| Provider Information | |||||||||
| NPI: | 1316243769 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE MEDICAL FOUNDATION | ||||||||
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| OtherOrganizationName: | ST JOSEPH HERITAGE HEALTHCARE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2141 N HARBOR BLVD STE 35000 | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928353831 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2141 N HARBOR BLVD STE 35000 | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146268630 | ||||||||
| FaxNumber: | 7146268659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2011 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | DUPLECHAN | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7143477790 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 6852510002 | 01 | CA | NSC | OTHER |