Healthcare Provider Details

I. General information

NPI: 1467758839
Provider Name (Legal Business Name): ST JUDE HOSPITAL YORBA LINDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

100 E VALENCIA MESA DR SUITE 310
FULLERTON CA
92835-3813
US

IV. Provider business mailing address

279 IMPERIAL HWY SUITE 730
FULLERTON CA
92835-1041
US

V. Phone/Fax

Practice location:
  • Phone: 714-446-5200
  • Fax: 714-446-5524
Mailing address:
  • Phone: 714-449-4841
  • Fax: 714-449-4956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN BENNETT
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 714-449-4800