Provider Demographics
NPI:1245383165
Name:PROVIDENCE TRINITYCARE HOSPICE
Entity Type:Organization
Organization Name:PROVIDENCE TRINITYCARE HOSPICE
Other - Org Name:
Other - Org Type:
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 1:5315 TORRANCE BLVD., SUITE B-1
Mailing Address - Street 2:PROVIDENCE TRINITYCARE HOSPICE
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4011
Mailing Address - Country:US
Mailing Address - Phone:310-543-3400
Mailing Address - Fax:310-316-2350
Practice Address - Street 1:5315 TORRANCE BLVD., SUITE B-1
Practice Address - Street 2:PROVIDENCE TRINITYCARE HOSPICE
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4011
Practice Address - Country:US
Practice Address - Phone:310-543-3400
Practice Address - Fax:310-316-2350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA980000880251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHPC01512FMedicaid
CA051512Medicare PIN