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General NPI Number Information
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NPI Number | 1538436274
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Entity Type | Organization
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Legal Business Name | ST, JUDE HERITAGE MEDICAL GROUP
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Dates
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Enumeration Date | 11/23/2011
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Last Update Date | 11/23/2011
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Provider Practice Location Address
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Address Line | 731 S HIGHLAND AVE
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City | FULLERTON
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State | CA
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Zip | 92832-2753
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Country | US
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Telephone | 714-446-5100
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Fax |
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Provider Business Mailing Address
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Address Line | 731 S. HIGHLAND AVE
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City | FULLERTON
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State | CA
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Zip | 92832-2753
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VP OF PHYSICIAN SERVICES
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Name | BOB O'NEIL
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Credential |
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Telephone | 714-578-8616
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 21377
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License Number State | CA
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