Healthcare Provider Details

I. General information

NPI: 1912472747
Provider Name (Legal Business Name): HIMELDA RIVERA CHURCHILL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HIMELDA RIVERA ORELLANA PAC

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 E 17TH ST STE 101
SANTA ANA CA
92701-2641
US

IV. Provider business mailing address

1206 E 17TH ST STE 101
SANTA ANA CA
92701-2641
US

V. Phone/Fax

Practice location:
  • Phone: 714-352-2911
  • Fax: 714-380-6235
Mailing address:
  • Phone: 714-352-2911
  • Fax: 714-380-6235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA56112
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: