Healthcare Provider Details

I. General information

NPI: 1801443510
Provider Name (Legal Business Name): PROVIDENCE MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W LA VETA AVE STE 200
ORANGE CA
92868-4301
US

IV. Provider business mailing address

200 W CENTER STREET PROMENADE STE 300
ANAHEIM CA
92805-3960
US

V. Phone/Fax

Practice location:
  • Phone: 714-835-1800
  • Fax: 714-835-1811
Mailing address:
  • Phone: 714-449-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL A DUPLECHAN
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 714-347-7790