Provider Demographics
NPI:1548380272
Name:DIGNITY HEALTH
Entity Type:Organization
Organization Name:DIGNITY HEALTH
Other - Org Name:MERCY HOSPICE MT. SHASTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-225-6121
Mailing Address - Street 1:914 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2143
Mailing Address - Country:US
Mailing Address - Phone:530-926-9321
Mailing Address - Fax:530-926-9396
Practice Address - Street 1:914 PINE ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2143
Practice Address - Country:US
Practice Address - Phone:530-926-9321
Practice Address - Fax:530-926-9396
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIGNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-29
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000756251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR721561129960670002OtherCHAMPUS TRICARE HOSPICE
CA721561129OtherIRS FEDERAL TAX ID #
CAHPC01736GMedicaid
CA051736Medicare Oscar/Certification