=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306383427
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. JUDE HOSPITAL YORBA LINDA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2017
-----------------------------------------------------
Last Update Date | 02/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 52 DISCOVERY
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-297-7748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 52 DISCOVERY
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92618-3105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-297-7748
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ADMINISTRATION OFFICER
-----------------------------------------------------
Name | JOHN BENNETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-449-4942
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------