Provider Demographics
NPI:1164429684
Name:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Other - Org Name:PROVIDENCE HOME HEALTH LA COUNTY NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:250 E OLIVE AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91502-1211
Mailing Address - Country:US
Mailing Address - Phone:818-953-4451
Mailing Address - Fax:747-229-2365
Practice Address - Street 1:250 E OLIVE AVE STE 202
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91502-1211
Practice Address - Country:US
Practice Address - Phone:818-953-4451
Practice Address - Fax:747-229-2365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA980000499251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA07627FMedicaid
CA057627Medicare Oscar/Certification