Provider Demographics
NPI:1144203142
Name:PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA LCM SUBACUTE CARE CTR
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA DBA LCM SUBACUTE CARE CTR
Other - Org Name:BAY HARBOR REHAB. CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:310-791-4511
Mailing Address - Street 1:3620 LOMITA BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3938
Mailing Address - Country:US
Mailing Address - Phone:310-791-4511
Mailing Address - Fax:310-791-4512
Practice Address - Street 1:3620 LOMITA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3938
Practice Address - Country:US
Practice Address - Phone:310-791-4511
Practice Address - Fax:310-791-4512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47225273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHB377200Medicaid