Healthcare Provider Details

I. General information

NPI: 1871607762
Provider Name (Legal Business Name): PROVIDENCE MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 W IMPERIAL HWY STE 110
BREA CA
92821-3814
US

IV. Provider business mailing address

200 W CENTER STREET PROMENADE STE 300
ANAHEIM CA
92805-3960
US

V. Phone/Fax

Practice location:
  • Phone: 714-449-4900
  • Fax:
Mailing address:
  • Phone: 714-449-4841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number091052001
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL A DUPLECHAN
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 714-347-7790