Provider Demographics
NPI:1285890624
Name:PROVIDENCE MEDICAL FOUNDATION
Entity type:Organization
Organization Name:PROVIDENCE MEDICAL FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUPLECHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-347-7790
Mailing Address - Street 1:200 W CENTER STREET PROMENADE STE 300
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3960
Mailing Address - Country:US
Mailing Address - Phone:714-449-4800
Mailing Address - Fax:714-449-4956
Practice Address - Street 1:1514 VALLEY VISTA DR
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3929
Practice Address - Country:US
Practice Address - Phone:909-860-1144
Practice Address - Fax:909-860-8307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACG4895OtherRAILROAD MEDICARE PROVIDER NUMBER
CACG4895OtherRAILROAD MEDICARE PROVIDER NUMBER