Provider Demographics
NPI:1730162579
Name:ST JOSEPH HEALTH SYSTEM HOME HEALTH AGENCY LLC
Entity type:Organization
Organization Name:ST JOSEPH HEALTH SYSTEM HOME HEALTH AGENCY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-358-9786
Mailing Address - Street 1:P.O. BOX 31001-1956
Mailing Address - Street 2:COMMERCIAL PAY LOCKBOX
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-1956
Mailing Address - Country:US
Mailing Address - Phone:714-712-9500
Mailing Address - Fax:714-712-7157
Practice Address - Street 1:200 W CENTER STREET PROMENADE STE 200C
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3960
Practice Address - Country:US
Practice Address - Phone:714-712-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-25
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA060000277251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330155323OtherMEDI-CAL
CA057600Medicare ID - Type Unspecified