Healthcare Provider Details

I. General information

NPI: 1518882539
Provider Name (Legal Business Name): ORDER OF MALTA CLINIC OF ORANGE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 N GRAND AVE STE C
SANTA ANA CA
92705-8758
US

IV. Provider business mailing address

21271 CALLE HORIZONTE
LAKE FOREST CA
92630-2145
US

V. Phone/Fax

Practice location:
  • Phone: 714-831-1541
  • Fax: 714-592-0736
Mailing address:
  • Phone: 949-309-8434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD KOZAK
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 949-309-8434