Provider Demographics
NPI:1679875942
Name:CENTER FOR COMPREHENSIVE CARE & DIAGNOSIS OF INHERITED BLOOD DISORDERS
Entity Type:Organization
Organization Name:CENTER FOR COMPREHENSIVE CARE & DIAGNOSIS OF INHERITED BLOOD DISORDERS
Other - Org Name:CENTER FOR INHERITED BLOOD DISORDERS (CIBD)
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:J
Authorized Official - Last Name:NUGENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-221-1200
Mailing Address - Street 1:701 S PARKER ST STE 1000
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4748
Mailing Address - Country:US
Mailing Address - Phone:657-375-0508
Mailing Address - Fax:714-600-4791
Practice Address - Street 1:701 S PARKER ST STE 1000
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4748
Practice Address - Country:US
Practice Address - Phone:714-221-1200
Practice Address - Fax:714-221-1299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001889261Q00000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1679875942Medicaid
CA1679875942Medicaid