Healthcare Provider Details

I. General information

NPI: 1578861613
Provider Name (Legal Business Name): DR. PATRICIA'S HEALTH CLUB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2011
Last Update Date: 03/01/2024
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W. STEWART DRIVE SUITE 508
ORANGE CA
92868-3856
US

IV. Provider business mailing address

211 E. COLUMBINE UNIT D
SANTA ANA CA
92707-4404
US

V. Phone/Fax

Practice location:
  • Phone: 714-549-6440
  • Fax: 714-549-6449
Mailing address:
  • Phone: 714-549-6440
  • Fax: 714-549-6449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberA72318
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES POTTER STIVERS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 949-226-1733