Provider Demographics
NPI:1578861613
Name:DR. PATRICIA'S HEALTH CLUB, INC.
Entity Type:Organization
Organization Name:DR. PATRICIA'S HEALTH CLUB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:POTTER
Authorized Official - Last Name:STIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-226-1733
Mailing Address - Street 1:211 E. COLUMBINE
Mailing Address - Street 2:UNIT D
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92707-4404
Mailing Address - Country:US
Mailing Address - Phone:714-549-6440
Mailing Address - Fax:714-549-6449
Practice Address - Street 1:1310 W. STEWART DRIVE
Practice Address - Street 2:SUITE 508
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3856
Practice Address - Country:US
Practice Address - Phone:714-549-6440
Practice Address - Fax:714-549-6449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-12
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208000000X, 252Y00000X
CAA72318252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty