MEDICARE: ORANGE HILLS MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0014X	Interventional Pain Medicine Physician		CA
2	111NS0005X	Sports Physician Chiropractor		CA

General Provider Information

NPI Number	:	1043654304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORANGE HILLS MEDICAL GROUP

Provider Business Mailing Address
First Line	:	295 IMPERIAL HWY
Second Line	:
City	:	FULLERTON
State	:	CA
Zip	:	92835-1020
Country	:	US
Telephone Number	:	714-770-8300
Fax Number	:

Provider Business Practice Location Address
First Line	:	1520 E LINCOLN AVE
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92865-1928
Country	:	US
Telephone Number	:	714-770-8350
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MARY LICEAGA
Credential	:	RN
Telephone Number	:	714-770-8366

Provider Enumeration Date	:	04/17/2013
Last Update Date	:	04/17/2013

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