Healthcare Provider Details

I. General information

NPI: 1316206592
Provider Name (Legal Business Name): ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 S HIGHLAND AVE
FULLERTON CA
92832-2753
US

IV. Provider business mailing address

731 S HIGHLAND AVE
FULLERTON CA
92832-2753
US

V. Phone/Fax

Practice location:
  • Phone: 714-446-5100
  • Fax: 714-449-0726
Mailing address:
  • Phone: 714-446-5100
  • Fax: 714-449-0726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY JASON BROWN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 208-899-9631