Provider Demographics
NPI:1790367779
Name:ST. JOSEPH - ST. THERESA MEDICAL, INC.
Entity Type:Organization
Organization Name:ST. JOSEPH - ST. THERESA MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:LILY
Authorized Official - Middle Name:H
Authorized Official - Last Name:DO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:714-760-4903
Mailing Address - Street 1:11180 WARNER AVE
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7501
Mailing Address - Country:US
Mailing Address - Phone:714-760-4903
Mailing Address - Fax:714-760-4349
Practice Address - Street 1:11180 WARNER AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7501
Practice Address - Country:US
Practice Address - Phone:714-760-4903
Practice Address - Fax:714-760-4349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1841433653Medicaid