Healthcare Provider Details

I. General information

NPI: 1164882999
Provider Name (Legal Business Name): CHILDREN'S HOSPITAL OF ORANGE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

IV. Provider business mailing address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

V. Phone/Fax

Practice location:
  • Phone: 714-509-8649
  • Fax: 714-509-8374
Mailing address:
  • Phone: 714-509-8649
  • Fax: 714-509-8374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MARK KELLY
Title or Position: DIRECTOR REVENUE CYCLE SUPPORT
Credential:
Phone: 714-509-7861