Provider Demographics
NPI:1467822411
Name:MEMORIALCARE HEALTH SYSTEM
Entity Type:Organization
Organization Name:MEMORIALCARE HEALTH SYSTEM
Other - Org Name:CANCER RISK AND PREVENTION PROGRAM
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:GENETIC COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:949-452-8854
Mailing Address - Street 1:24302 PASEO DE VALENCIA
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24302 PASEO DE VALENCIA
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3115
Practice Address - Country:US
Practice Address - Phone:949-452-8854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGC000665170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170300000XOther Service ProvidersGenetic Counselor, MSGroup - Single Specialty