Provider Demographics
NPI:1467643726
Name:FOUNTAIN VALLEY OFFICE
Entity Type:Organization
Organization Name:FOUNTAIN VALLEY OFFICE
Other - Org Name:PEDIATRIC SUBSPECIALTY FACULTY, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:FARACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-516-4295
Mailing Address - Street 1:455 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3835
Mailing Address - Country:US
Mailing Address - Phone:714-516-4295
Mailing Address - Fax:
Practice Address - Street 1:11100 WARNER AVE STE 254
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7502
Practice Address - Country:US
Practice Address - Phone:714-516-4295
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC SUBSPECIALTY FACULTY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty