Provider Demographics
NPI:1871607762
Name:PROVIDENCE MEDICAL FOUNDATION
Entity type:Organization
Organization Name:PROVIDENCE MEDICAL FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DUPLECHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-347-7790
Mailing Address - Street 1:200 W CENTER STREET PROMENADE STE 300
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3960
Mailing Address - Country:US
Mailing Address - Phone:714-449-4841
Mailing Address - Fax:
Practice Address - Street 1:955 W IMPERIAL HWY STE 110
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3814
Practice Address - Country:US
Practice Address - Phone:714-449-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207V00000X, 261QR0200X
CA091052001332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Multi-Specialty
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0062058Medicaid
CALAB76828FMedicaid
CAGR0062050Medicaid
CAGR0062051Medicaid
CAGR0062053Medicaid
CAGR0062056Medicaid
CAGR0062059Medicaid
CAGR0062057Medicaid
CAGR006205AMedicaid
CAGR0062054Medicaid
CAGR0062055Medicaid
CAGR0062052Medicaid
CALAB76828FMedicaid
CAGR0062051Medicaid
CAGR0062054Medicaid
CAW13074CMedicare PIN