Healthcare Provider Details

I. General information

NPI: 1619403854
Provider Name (Legal Business Name): RITA R ELLITHORPE MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2017
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 PARKCENTER DR STE 100
SANTA ANA CA
92705-3524
US

IV. Provider business mailing address

825 PARKCENTER DR STE 100
SANTA ANA CA
92705-3524
US

V. Phone/Fax

Practice location:
  • Phone: 714-544-1521
  • Fax: 714-544-1904
Mailing address:
  • Phone: 714-544-1521
  • Fax: 888-415-3257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberG83575
License Number StateCA

VIII. Authorized Official

Name: TALON ELLITHORPE
Title or Position: PRACTICE MANAGER
Credential: CMPE
Phone: 714-805-6173