Provider Demographics
NPI:1225397409
Name:ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Entity Type:Organization
Organization Name:ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Other - Org Name:ST. JUDE DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-899-9631
Mailing Address - Street 1:731 S HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-2753
Mailing Address - Country:US
Mailing Address - Phone:714-522-8723
Mailing Address - Fax:714-522-4182
Practice Address - Street 1:7758 KNOTT AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-2420
Practice Address - Country:US
Practice Address - Phone:714-522-8723
Practice Address - Fax:714-522-4182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental