Provider Demographics
NPI:1639544505
Name:THE
Entity Type:Organization
Organization Name:THE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-730-1920
Mailing Address - Street 1:831 W LAS PALMAS DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1439
Mailing Address - Country:US
Mailing Address - Phone:714-403-9942
Mailing Address - Fax:714-680-8314
Practice Address - Street 1:1215 W IMPERIAL HWY STE 101
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3738
Practice Address - Country:US
Practice Address - Phone:714-680-8335
Practice Address - Fax:714-680-8314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA064054261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center