Provider Demographics
NPI:1043654304
Name:ORANGE HILLS MEDICAL GROUP
Entity type:Organization
Organization Name:ORANGE HILLS MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LICEAGA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:714-770-8366
Mailing Address - Street 1:295 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1020
Mailing Address - Country:US
Mailing Address - Phone:714-770-8300
Mailing Address - Fax:
Practice Address - Street 1:1520 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865-1928
Practice Address - Country:US
Practice Address - Phone:714-770-8350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111NS0005X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty