Healthcare Provider Details

I. General information

NPI: 1114317872
Provider Name (Legal Business Name): SUSAN SAMUELI CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 BRISTOL ST SUITE 200
COSTA MESA CA
92626-8605
US

IV. Provider business mailing address

PO BOX 54509
LOS ANGELES CA
90054-0509
US

V. Phone/Fax

Practice location:
  • Phone: 714-424-9001
  • Fax: 714-424-9005
Mailing address:
  • Phone: 714-456-6585
  • Fax: 714-456-8101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN A. HEYDT
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 714-456-2986