Provider Demographics
NPI:1497241541
Name:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Entity type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-358-9786
Mailing Address - Street 1:PO BOX 541024
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-1024
Mailing Address - Country:US
Mailing Address - Phone:310-303-7496
Mailing Address - Fax:310-303-7575
Practice Address - Street 1:1386 W 7TH ST # A
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3517
Practice Address - Country:US
Practice Address - Phone:310-241-4330
Practice Address - Fax:310-241-4342
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORINA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-02
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
CA930000142282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No251S00000XAgenciesCommunity/Behavioral Health