Provider Demographics
NPI:1386654077
Name:LODI MEMORIAL HOSPITAL ASSOCIATION INC
Entity Type:Organization
Organization Name:LODI MEMORIAL HOSPITAL ASSOCIATION INC
Other - Org Name:LODI MEMORIAL PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-339-7477
Mailing Address - Street 1:PO BOX 884577
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90088-4577
Mailing Address - Country:US
Mailing Address - Phone:209-334-3411
Mailing Address - Fax:209-339-7659
Practice Address - Street 1:2415 W VINE ST STE 100
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3731
Practice Address - Country:US
Practice Address - Phone:209-333-3135
Practice Address - Fax:209-339-7659
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LODI MEMORIAL HOSPITAL ASSOCIATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-08
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000056261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02721ZOtherBLUE SHIELD PROV GRP
CAGR0086831Medicaid