Provider Demographics
NPI:1073673737
Name:MEMORIAL MEDICAL CENTER
Entity Type:Organization
Organization Name:MEMORIAL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP SHARED SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:TRENT
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-297-8555
Mailing Address - Street 1:PO BOX 740152
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0152
Mailing Address - Country:US
Mailing Address - Phone:955-398-1633
Mailing Address - Fax:
Practice Address - Street 1:1700 COFFEE ROAD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2803
Practice Address - Country:US
Practice Address - Phone:209-526-4500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA352732282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050557Medicare Oscar/Certification