Provider Demographics
NPI:1306384375
Name:ST. JUDE HOSPITAL YORBA LINDA
Entity Type:Organization
Organization Name:ST. JUDE HOSPITAL YORBA LINDA
Other - Org Name:DRIVE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ADMINISTRATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-449-4942
Mailing Address - Street 1:200 W CENTER STREET PROMENADE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3960
Mailing Address - Country:US
Mailing Address - Phone:949-275-5665
Mailing Address - Fax:
Practice Address - Street 1:3355 MICHELSON DR
Practice Address - Street 2:SUITE 490
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-0684
Practice Address - Country:US
Practice Address - Phone:949-672-9900
Practice Address - Fax:949-526-8385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site