Provider Demographics
NPI:1316243769
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:ANN
Authorized Official - Last Name:DUPLECHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-347-7790
Mailing Address - Street 1:2141 N HARBOR BLVD STE 35000
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2141 N HARBOR BLVD STE 35000
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835
Practice Address - Country:US
Practice Address - Phone:714-626-8630
Practice Address - Fax:714-626-8659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-02
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6852510002OtherNSC
CA6852510002OtherNSC