Provider Demographics
NPI:1861410581
Name:DIGNITY HEALTH MEDICAL FOUNDATION
Entity type:Organization
Organization Name:DIGNITY HEALTH MEDICAL FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HYLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-851-2559
Mailing Address - Street 1:PO BOX 742027
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-2027
Mailing Address - Country:US
Mailing Address - Phone:916-379-2840
Mailing Address - Fax:916-859-1106
Practice Address - Street 1:3132 W MARCH LN
Practice Address - Street 2:SUITE 5
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2354
Practice Address - Country:US
Practice Address - Phone:209-475-5500
Practice Address - Fax:209-475-5515
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIGNITY HEALTH MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7291OtherSTOCKTON LOC - HEALTHNET
CAGR0091671Medicaid
371518341OtherSTOCKTON LOC - IRS SP TAX
CAZZZ66457ZOtherBLUE SHIELD
CAZZZ66457ZOtherBLUE SHIELD