Healthcare Provider Details

I. General information

NPI: 1851325906
Provider Name (Legal Business Name): UNIVERSITY OF CALIFORNIA IRVINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N MAIN ST
SANTA ANA CA
92701
US

IV. Provider business mailing address

1500 S DOUGLASS RD #200, RT 183
ANAHEIM CA
92806-6912
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-6785
  • Fax:
Mailing address:
  • Phone: 714-509-6266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: GINA CHURCHILL
Title or Position: REIMBURSEMENT DIRECTOR
Credential:
Phone: 714-509-6266