Provider Demographics
NPI:1063657138
Name:TUSTIN HOSPITAL AND MEDICAL CENTER
Entity Type:Organization
Organization Name:TUSTIN HOSPITAL AND MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST. DIRECTOR OF PFS
Authorized Official - Prefix:
Authorized Official - First Name:RONNELL
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-669-5832
Mailing Address - Street 1:14662 NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6064
Mailing Address - Country:US
Mailing Address - Phone:714-669-5832
Mailing Address - Fax:714-669-5986
Practice Address - Street 1:14662 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6064
Practice Address - Country:US
Practice Address - Phone:714-669-5832
Practice Address - Fax:714-669-5986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA052053282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA052053Medicare Oscar/Certification