Basic Information
| Provider Information | |||||||||
| NPI: | 1831587955 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JUDE HOSPITAL YORBA LINDA | ||||||||
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| OtherOrganizationName: | ST JOSEPH HERITAGE HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 279 IMPERIAL HWY | ||||||||
| Address2: | SUITE 730 | ||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928351041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144494841 | ||||||||
| FaxNumber: | 7144494956 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 LYNCH CREEK WAY | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949542357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077637403 | ||||||||
| FaxNumber: | 7077890900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2014 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | JUST | ||||||||
| AuthorizedOfficialFirstName: | BOB | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7073038355 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 213E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 6852510005 | 01 | CA | NSC | OTHER |