Healthcare Provider Details

I. General information

NPI: 1427305960
Provider Name (Legal Business Name): PROVIDENCE MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26522 LA ALAMEDA SUITE 120
MISSION VIEJO CA
92691-6330
US

IV. Provider business mailing address

PO BOX 31001 - 1920
PASADENA CA
91110-1920
US

V. Phone/Fax

Practice location:
  • Phone: 949-364-9631
  • Fax:
Mailing address:
  • Phone: 714-449-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
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