Healthcare Provider Details

I. General information

NPI: 1154912962
Provider Name (Legal Business Name): HERITAGE 88 HOLDINGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 S MAIN ST STE 100
ORANGE CA
92868-3852
US

IV. Provider business mailing address

2256 HERITAGE DR
COSTA MESA CA
92627-1679
US

V. Phone/Fax

Practice location:
  • Phone: 714-704-1900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VANESSA DUMONT
Title or Position: NURSE PRACTITIONER
Credential:
Phone: 415-250-6769