Provider Demographics
NPI:1033430319
Name:KAISER PERMANENTE
Entity Type:Organization
Organization Name:KAISER PERMANENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARICA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-857-4142
Mailing Address - Street 1:6041 CADILLAC AVE
Mailing Address - Street 2:ENDOCRINOLOGY DEPT #220
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-1702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 S ARNAZ DR APT 3
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2818
Practice Address - Country:US
Practice Address - Phone:213-215-5142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17657261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA17657Medicaid
CA17657Medicaid