Provider Demographics
NPI:1053653873
Name:DIGNITY HEALTH MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:DIGNITY HEALTH MEDICAL FOUNDATION
Other - Org Name:DIGNITY HEALTH MEDICAL GROUP - INLAND EMPIRE, A SERVICE OF DIGNITY HEA
Other - Org Type:Doing Business As
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 743260
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-3260
Mailing Address - Country:US
Mailing Address - Phone:916-379-2726
Mailing Address - Fax:916-853-7874
Practice Address - Street 1:4240 HIGHLAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-2764
Practice Address - Country:US
Practice Address - Phone:805-383-5258
Practice Address - Fax:805-614-5901
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIGNITY HEALTH MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-19
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
364745424OtherIRS - SPECIAL PURPOSE TIN