Provider Demographics
NPI:1255731428
Name:FOUNTIAN VALLEY REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:FOUNTIAN VALLEY REGIONAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RNFA
Authorized Official - Prefix:
Authorized Official - First Name:YOUNGHI
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:714-966-8128
Mailing Address - Street 1:21136 SUNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-3317
Mailing Address - Country:US
Mailing Address - Phone:909-598-9908
Mailing Address - Fax:
Practice Address - Street 1:17100 EUCLID ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4004
Practice Address - Country:US
Practice Address - Phone:714-966-8128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA364193261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical