Provider Demographics
NPI:1629374053
Name:ST JUDE HOSPITAL YORBA LINDA
Entity Type:Organization
Organization Name:ST JUDE HOSPITAL YORBA LINDA
Other - Org Name:ST JOSEPH HERITAGE HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-449-4800
Mailing Address - Street 1:279 IMPERIAL HWY
Mailing Address - Street 2:SUITE 730
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1041
Mailing Address - Country:US
Mailing Address - Phone:714-449-4841
Mailing Address - Fax:
Practice Address - Street 1:1514 VALLEY VISTA DR
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3929
Practice Address - Country:US
Practice Address - Phone:909-860-1144
Practice Address - Fax:909-860-8307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-02
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13074FMedicare PIN