Basic Information
Provider Information | |||||||||
NPI: | 1104013879 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MINUTECLINIC DIAGNOSTIC MEDICAL GROUP OF ORANGE COUNTY, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 772 | ||||||||
Address2: | MINUTECLINIC CREDENTIALING | ||||||||
City: | WOONSOCKET | ||||||||
State: | RI | ||||||||
PostalCode: | 028950784 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8663892727 | ||||||||
FaxNumber: | 4014063539 | ||||||||
Practice Location | |||||||||
Address1: | 1150 BAKER ST | ||||||||
Address2: |   | ||||||||
City: | COSTA MESA | ||||||||
State: | CA | ||||||||
PostalCode: | 926264111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8663892727 | ||||||||
FaxNumber: | 4014063539 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2007 | ||||||||
LastUpdateDate: | 02/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PINCINCE | ||||||||
AuthorizedOfficialFirstName: | DEBORAH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 4017703813 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363LF0000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | DO3833 | 01 | CA | MEDICARE RAILROAD | OTHER | DO3834 | 01 | CA | MEDICARE RAILROAD | OTHER |