Healthcare Provider Details

I. General information

NPI: 1043654304
Provider Name (Legal Business Name): ORANGE HILLS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 E LINCOLN AVE
ORANGE CA
92865-1928
US

IV. Provider business mailing address

295 IMPERIAL HWY
FULLERTON CA
92835-1020
US

V. Phone/Fax

Practice location:
  • Phone: 714-770-8350
  • Fax:
Mailing address:
  • Phone: 714-770-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MARY LICEAGA
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 714-770-8366