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General NPI Number Information
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NPI Number | 1871607762
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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 | 08/18/2006
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Last Update Date | 03/17/2025
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Provider Practice Location Address
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Address Line | 955 W IMPERIAL HWY STE 110
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City | BREA
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State | CA
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Zip | 92821-3814
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Country | US
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Telephone | 714-449-4900
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Fax |
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Provider Business Mailing Address
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Address Line | 200 W CENTER STREET PROMENADE STE 300
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City | ANAHEIM
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State | CA
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Zip | 92805-3960
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Country | US
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Telephone | 714-449-4841
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Fax |
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Authorized Official
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Title or Position | CHIEF ADMINISTRATIVE OFFICER
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Name | JILL A DUPLECHAN
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Credential |
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Telephone | 714-347-7790
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology 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 | 261QR0200X
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Taxonomy Name | Radiology Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 332BX2000X
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Taxonomy Name | Oxygen Equipment & Supplies (DME)
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License Number | 091052001
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License Number State | CA
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Taxonomy #4
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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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