Covered Entity Details

RRC050567-28 MISSION HOSPITAL REG MEDICAL CENTER (Approved) - information as of 5/4/2025 10:25:21 PM

Main Details

Name

MISSION HOSPITAL REG MEDICAL CENTER

Subdivision Name

Providence Mission Hospital - Cancer Institute PET - Cancer Institute PET

Type

Rural Referral Center

Rural

Yes

340B ID

RRC050567-28

Medicare Provider Number

050567

Outpatient Facility Provider Number

Additional Details

Current Program Status

Approved

Registration Date

4/1/2025

Participating Start Date

7/1/2025

Participating Approval Date

4/7/2025

Last Recertification Date

Contacts

Authorizing Official

St. Joseph Hospital, Orange
Eileen Haubl, Chief Financial Officer
(949) 364-1400 Ext: 5408

Primary Contact

Mission Hospital
Nha-Uyen Tran, 340B Pharmacist Specialist
(949) 364-1400 Ext: 2220

Addresses

Street Address

27799 Medical Center Road
160
Mission Viejo, CA 92691

Billing Address

St. Joseph Health Shared Services Accounts Payable
3345 Michelson Drive
Irvine, CA 92612

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
CA	ZZT40567I,ZZT30567I	1003956913,1093945412,1912108002,1992752315

Shipping Addresses

Same as Street Address

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
RRC050567-01	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - OUTPATIENT ENDOSCOPY	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-02	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - OUTPATIENT BEHAVIORAL CARE CENTER	27800 MEDICAL CENTER RD	MISSION VIEJO	CA	Terminated
RRC050567-03	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Chemical Dependency Outpatient	31872 COAST HWY	LAGUNA BEACH	CA	Terminated
RRC050567-04	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - OUTPATIENT BEHAVIORAL HEALTH	31862 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-05	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Cardiology	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-06	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Emergency Department	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-07	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - OUTPATIENT REHABILITAITON	26732 CROWN VALLEY PKWY	MISSION VIEJO	CA	Terminated
RRC050567-08	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Surgical Services	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-09	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - OUTPATIENT PHYSICAL THERAPY	27882 FORBES RD	LAGUNA NIGUEL	CA	Terminated
RRC050567-10	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - CARDIOPULMONARY REHABILITATION	26732 CROWN VALLEY PKWY	MISSION VIEJO	CA	Terminated
RRC050567-11	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - MRI	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-12	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Ultrasound	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-13	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Radiology/Mammography	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-14	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Nuclear Medicine	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-15	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Clinical Laboratory	31872 COAST HWY	LAGUNA BEACH	CA	Terminated
RRC050567-16	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Respiratory Therapy	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-17	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - WOMEN'S WELLNESS	26732 CROWN VALLEY PKWY	MISSION VIEJO	CA	Active
RRC050567-18	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - CT Scan	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-19	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - OUTPATIENT IMAGING	27871 MEDICAL CENTER RD	MISSION VIEJO	CA	Terminated
RRC050567-20	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL LAGUNA Beach - Physical Therapy and Rehab Services	31872 COAST HWY	LAGUNA BEACH	CA	Active
RRC050567-21	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	MISSION HOSPITAL - MISSION HOSPITAL REGIONAL MEDICAL CENTER - PERINATAL DIAGNOSTICS & TREATMENT CLINIC	27800 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-22	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	PROVIDENCE MISSION HOSPITAL - Cancer Institute Radiology	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-23	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	PROVIDENCE MISSION HOSPITAL - Cancer Institute Ultrasound	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-24	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	PROVIDENCE MISSION HOSPITAL - Cancer Institute Radiation Onc	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-25	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	PROVIDENCE MISSION HOSPITAL - Cancer Institute MRI	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-26	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	PROVIDENCE MISSION HOSPITAL - Cancer Institute CT Scan	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-27	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	PROVIDENCE MISSION HOSPITAL - Cancer Institute Infusion Center	27799 MEDICAL CENTER RD	MISSION VIEJO	CA	Active
RRC050567-28	Child	RRC	MISSION HOSPITAL REG MEDICAL CENTER	Providence Mission Hospital - Cancer Institute PET - Cancer Institute PET	27799 Medical Center Road	Mission Viejo	CA	Approved

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Signed By	Insert	New Registration		Haubl, Eileen Chief Financial Officer St. Joseph Hospital, Orange 9493641400-5408	4/7/2025 2:14 PM
Details	340B ID	Update	New Registration		RRC050567-28	4/7/2025 2:14 PM
Details	Entity Subname	Update	New Registration	Providence Mission Hospital - Cancer Institute PET	Providence Mission Hospital - Cancer Institute PET - Cancer Institute PET	4/7/2025 2:14 PM
Dates	Participating Approval Date	Update	New Registration		4/7/2025 2:14:00 PM	4/7/2025 2:14 PM
Details	State	Update	New Registration	Pending	Approved	4/7/2025 2:14 PM
Dates	Signed By Date	Update	New Registration		4/2/2025 8:16:53 PM	4/7/2025 2:14 PM
Dates	Start Date	Update	New Registration		7/1/2025 12:00:00 AM	4/7/2025 2:14 PM
Addresses	Main Address	Insert	New Registration		27799 Medical Center Road 160 Mission Viejo, CA 92691	4/1/2025 2:18 PM
Addresses	Billing Address	Insert	New Registration		St. Joseph Health Shared Services Accounts Payable 3345 Michelson Drive Irvine, CA 92612	4/1/2025 2:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2025 2:18 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		ZZT40567I	4/1/2025 2:18 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/1/2025 2:18 PM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/1/2025 2:18 PM
Medicaid Billing	Medicaid: Number	Insert	New Registration		ZZT30567I	4/1/2025 2:18 PM
Medicaid Billing	Medicaid: State	Insert	New Registration		CA	4/1/2025 2:18 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1003956913	4/1/2025 2:18 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/1/2025 2:18 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1093945412	4/1/2025 2:18 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/1/2025 2:18 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1912108002	4/1/2025 2:18 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/1/2025 2:18 PM
Medicaid Billing	NPI: Number	Insert	New Registration		1992752315	4/1/2025 2:18 PM
Medicaid Billing	NPI: State	Insert	New Registration		CA	4/1/2025 2:18 PM
Contacts	Authorizing Official	Insert	New Registration		Haubl, Eileen Chief Financial Officer St. Joseph Hospital, Orange 9493641400-5408	4/1/2025 2:18 PM
Contacts	Primary Contact	Insert	New Registration		Tran, Nha-Uyen 340B Pharmacist Specialist Mission Hospital 9493641400-2220	4/1/2025 2:18 PM
Details	Assistance Received From Date	Insert	New Registration			4/1/2025 2:18 PM
Details	Assistance Received To Date	Insert	New Registration			4/1/2025 2:18 PM
Details	Last Recertification Date	Insert	New Registration			4/1/2025 2:18 PM
Details	Grant Number	Insert	New Registration			4/1/2025 2:18 PM
Details	340B ID	Insert	New Registration			4/1/2025 2:18 PM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/1/2025 2:18 PM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/1/2025 2:18 PM
Details	Medicare Provider Number	Insert	New Registration		050567	4/1/2025 2:18 PM
Details	Entity Name	Insert	New Registration		MISSION HOSPITAL REG MEDICAL CENTER	4/1/2025 2:18 PM
Details	NOFO Number	Insert	New Registration			4/1/2025 2:18 PM
Details	Program Code	Insert	New Registration		RRC	4/1/2025 2:18 PM
Details	Entity Subname	Insert	New Registration		Providence Mission Hospital - Cancer Institute PET	4/1/2025 2:18 PM
Dates	Participating Approval Date	Insert	New Registration			4/1/2025 2:18 PM
Details	State	Insert	New Registration		Pending	4/1/2025 2:18 PM
Dates	Registration Date	Insert	New Registration		4/1/2025 2:18:20 PM	4/1/2025 2:18 PM
Dates	Signed By Date	Insert	New Registration			4/1/2025 2:18 PM
Dates	Start Date	Insert	New Registration			4/1/2025 2:18 PM
Terminations	Termination Comments	Insert	New Registration			4/1/2025 2:18 PM
Terminations	Termination Date	Insert	New Registration			4/1/2025 2:18 PM
Terminations	Termination Effective Date	Insert	New Registration			4/1/2025 2:18 PM
Terminations	Termination Reason	Insert	New Registration			4/1/2025 2:18 PM