Provider Demographics
NPI:1598790529
Name:UNIVERSITY OF CALIFORNIA IRVINE
Entity Type:Organization
Organization Name:UNIVERSITY OF CALIFORNIA IRVINE
Other - Org Name:UCI FAMILY HEALTH CENTER - ANAHEIM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REIMBURSEMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURCHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-509-6266
Mailing Address - Street 1:1500 S DOUGLASS RD #200, RT 183
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-6912
Mailing Address - Country:US
Mailing Address - Phone:714-509-6299
Mailing Address - Fax:
Practice Address - Street 1:2441 W LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2658
Practice Address - Country:US
Practice Address - Phone:657-282-6356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UC IRVINE MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-11
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEXEMPT261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP11874FMedicaid
CAZZT12120FMedicaid
CABCP11874FMedicaid
CAFHC70104FMedicaid
CAZZT12120FMedicaid
CAW4678Medicare ID - Type UnspecifiedFQHC MEDICARE PART B