Healthcare Provider Details

I. General information

NPI: 1194118018
Provider Name (Legal Business Name): CHILDREN'S HOSPITAL OF ORANGE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2015
Last Update Date: 03/23/2015
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 Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateCA
# 8
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

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