Healthcare Provider Details

I. General information

NPI: 1063534501
Provider Name (Legal Business Name): ST. JUDE HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7758 KNOTT AVE
BUENA PARK CA
90620-2420
US

IV. Provider business mailing address

7758 KNOTT AVE
BUENA PARK CA
90620-2420
US

V. Phone/Fax

Practice location:
  • Phone: 714-522-8723
  • Fax:
Mailing address:
  • Phone: 714-522-8723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: MR. BARRY ROSS
Title or Position: VICE PRESIDENT, HEALTHY COMMUNITIES
Credential: RN
Phone: 714-992-3164