Healthcare Provider Details

I. General information

NPI: 1043401870
Provider Name (Legal Business Name): PROVIDENCE - CARDIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 W STEWART DR STE 212
ORANGE CA
92868-3837
US

IV. Provider business mailing address

455 S MAIN ST
ORANGE CA
92868-3835
US

V. Phone/Fax

Practice location:
  • Phone: 714-516-4295
  • Fax:
Mailing address:
  • Phone: 714-516-4295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: ELIZABETH M FARACE
Title or Position: MANAGER
Credential:
Phone: 714-516-4295