Provider Demographics
NPI:1851440226
Name:HEALTHSOURCE OF ANAHEIM INC
Entity Type:Organization
Organization Name:HEALTHSOURCE OF ANAHEIM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMAL
Authorized Official - Middle Name:F
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:714-772-7100
Mailing Address - Street 1:4760 DEVONPORT CIR
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-2609
Mailing Address - Country:US
Mailing Address - Phone:714-772-7100
Mailing Address - Fax:
Practice Address - Street 1:716 S STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-4526
Practice Address - Country:US
Practice Address - Phone:714-772-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05681ZOtherBLUE SHIELD GROUP ID