Provider Demographics
NPI:1639715709
Name:PROVIDENCE MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL FOUNDATION
Other - Org Name:ST JOSEPH HERITAGE HEALTHCARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUPLECHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-347-7790
Mailing Address - Street 1:200 W CENTER STREET PROMENADE STE 300
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3960
Mailing Address - Country:US
Mailing Address - Phone:714-449-4800
Mailing Address - Fax:
Practice Address - Street 1:200 W CENTER STREET PROMENADE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3960
Practice Address - Country:US
Practice Address - Phone:147-123-5007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-22
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty