Healthcare Provider Details

I. General information

NPI: 1316243769
Provider Name (Legal Business Name): PROVIDENCE MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 N HARBOR BLVD STE 35000
FULLERTON CA
92835
US

IV. Provider business mailing address

PO BOX 31001 - 1920
PASADENA CA
91110-1920
US

V. Phone/Fax

Practice location:
  • Phone: 714-626-8630
  • Fax: 714-626-8659
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DONALD W. ANDERSON JR.
Title or Position: ASSISTANT SECRETARY OF ENROLLMENTS
Credential:
Phone: 425-358-9786