Basic Information
| Provider Information | |||||||||
| NPI: | 1962625202 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOSEPH HOSPITAL OF ORANGE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LA AMISTAD DE JOSE FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 353 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147718006 | ||||||||
| FaxNumber: | 7147448630 | ||||||||
| Practice Location | |||||||||
| Address1: | 353 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147718006 | ||||||||
| FaxNumber: | 7147448630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARRETT | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7147718000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | CMM70367F | 05 | CA | MEDICAID | EAP70367F | 01 | CA | (EAPC) EXPANDED ACCESS PR | OTHER | G93665-01 | 01 | CA | DENTI-CAL | OTHER |