Healthcare Provider Details

I. General information

NPI: 1972909927
Provider Name (Legal Business Name): ST.JUDE HERITAGE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2014
Last Update Date: 11/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W LA VETA AVE STE 710
ORANGE CA
92868-4306
US

IV. Provider business mailing address

1010 W LA VETA AVE STE 710
ORANGE CA
92868-4306
US

V. Phone/Fax

Practice location:
  • Phone: 714-835-2724
  • Fax: 714-835-2753
Mailing address:
  • Phone: 714-835-2724
  • Fax: 714-835-2753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG86364
License Number StateCA

VIII. Authorized Official

Name: MRS. JACQUELINE RAMIREZ
Title or Position: OPERATIONS SUPERVISOR
Credential:
Phone: 714-835-2724