Healthcare Provider Details

I. General information

NPI: 1386915593
Provider Name (Legal Business Name): SANTIAGO CANYON COLLEGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2012
Last Update Date: 01/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8045 EAST CHAPMAN AVE BUILDING T - 102 STUDENT HEALTH
ORANGE CA
92869-4773
US

IV. Provider business mailing address

8045 EAST CHAPMAN AVE BUILDING T - 102 STUDENT HEALTH
ORANGE CA
92869-4773
US

V. Phone/Fax

Practice location:
  • Phone: 714-628-4773
  • Fax: 714-628-4749
Mailing address:
  • Phone: 714-628-4773
  • Fax: 714-628-4749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY20612
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberB307289
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberZ0A8350
License Number StateCA

VIII. Authorized Official

Name: DR. RENEE E. YOCAM
Title or Position: COLLEGE PHYSICIAN
Credential: MD, DO
Phone: 714-628-4773