Healthcare Provider Details

I. General information

NPI: 1104169606
Provider Name (Legal Business Name): CHILDREN'S HOSPITAL OF ORANGE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 10/17/2013
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: 714-633-4020
  • Fax: 714-953-5462
Mailing address:
  • Phone: 714-633-4020
  • Fax: 714-953-5462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MARK KELLY
Title or Position: DIRECTOR, CS BUSINESS SERVICES
Credential:
Phone: 714-509-7964