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General NPI Number Information
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NPI Number | 1427305960
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Entity Type | Organization
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Legal Business Name | PROVIDENCE MEDICAL FOUNDATION
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Dates
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Enumeration Date | 08/14/2012
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Last Update Date | 12/01/2025
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Provider Practice Location Address
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Address Line | 26522 LA ALAMEDA SUITE 120
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City | MISSION VIEJO
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State | CA
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Zip | 92691-6330
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Country | US
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Telephone | 949-364-9631
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 31001 - 1920
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City | PASADENA
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State | CA
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Zip | 91110-1920
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Country | US
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Telephone | 714-449-4800
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Fax |
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Authorized Official
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Title or Position | ASSISTANT SECRETARY OF ENROLLMENTS
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Name | DONALD W. ANDERSON JR.
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Credential |
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Telephone | 425-358-9786
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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