Provider Demographics
NPI:1932324555
Name:ST. JUDE HOSPITAL, INC.
Entity Type:Organization
Organization Name:ST. JUDE HOSPITAL, INC.
Other - Org Name:ST. JUDE NEIGHBORHOOD HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, HEALTHY COMMUNITIES
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:714-446-5100
Mailing Address - Street 1:731 SOUTH HIGHLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832
Mailing Address - Country:US
Mailing Address - Phone:714-446-5100
Mailing Address - Fax:
Practice Address - Street 1:731 SOUTH HIGHLAND AVENUE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832
Practice Address - Country:US
Practice Address - Phone:714-446-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM71168FMedicaid