Provider Demographics
NPI:1568021772
Name:ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Entity Type:Organization
Organization Name:ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Other - Org Name:LA AMISTAD MOBILE MEDICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
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:
Mailing Address - Fax:
Practice Address - Street 1:1934 E TAFT AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865-4702
Practice Address - Country:US
Practice Address - Phone:714-771-8006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-11
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care