Provider Demographics
NPI:1477790517
Name:PROVIDENCE MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL FOUNDATION
Other - Org Name:ST JOSEPH HERITAGE HEALTHCARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUPLECHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-347-7790
Mailing Address - Street 1:200 W CENTER STREET PROMENADE STE 300
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3960
Mailing Address - Country:US
Mailing Address - Phone:714-449-4800
Mailing Address - Fax:714-449-4956
Practice Address - Street 1:2752 HARRISON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4738
Practice Address - Country:US
Practice Address - Phone:707-268-0190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABH969Medicare PIN
CAW13074CMedicare PIN