Provider Demographics
NPI:1427093046
Name:HEAD AND NECK ASSOCIATES OF ORANGE COUNTY AN INCORPRATE
Entity type:Organization
Organization Name:HEAD AND NECK ASSOCIATES OF ORANGE COUNTY AN INCORPRATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SUPANCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-364-4361
Mailing Address - Street 1:26726 CROWN VALLEY KWY
Mailing Address - Street 2:#200
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8003
Mailing Address - Country:US
Mailing Address - Phone:949-364-4361
Mailing Address - Fax:949-364-4495
Practice Address - Street 1:26726 CROWN VALLEY PKWY
Practice Address - Street 2:#200
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-8003
Practice Address - Country:US
Practice Address - Phone:949-364-4361
Practice Address - Fax:949-364-4495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2014-11-21
Deactivation Date:2007-09-25
Deactivation Code:
Reactivation Date:2008-02-27
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR006971Medicaid
CAGR0069701Medicaid
CAGR006970Medicaid
CAGR0069701Medicaid