Basic Information
| Provider Information | |||||||||
| NPI: | 1780169524 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S HOSPITAL OF ORANGE COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHOC PRIMARY CARE NETWORK | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 W LA VETA AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684203 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 W LA VETA AVE | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887702462 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2018 | ||||||||
| LastUpdateDate: | 10/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, CS BUSINESS SERIVICES | ||||||||
| AuthorizedOfficialTelephone: | 7145097861 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHILDREN'S HOSPITAL OF ORANGE COUNTY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 2080B0002X | N | 193200000X MULTI-SPECIALTY GROUP | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.