Basic Information
Provider Information | |||||||||
NPI: | 1487229787 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. JUDE NEIGHBORHOOD HEALTH CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 731 S HIGHLAND AVE | ||||||||
Address2: |   | ||||||||
City: | FULLERTON | ||||||||
State: | CA | ||||||||
PostalCode: | 928322753 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7144465100 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 330 E. ORANGEWOOD AVE | ||||||||
Address2: |   | ||||||||
City: | ANAHEIM | ||||||||
State: | CA | ||||||||
PostalCode: | 92802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7144465100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2021 | ||||||||
LastUpdateDate: | 05/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BROWN | ||||||||
AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
AuthorizedOfficialMiddleName: | JASON | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2088999631 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QD0000X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QP1100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | 261QP2300X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.