Provider Demographics
NPI:1558613059
Name:ST. LUKE MEDICAL CENTER INC.
Entity Type:Organization
Organization Name:ST. LUKE MEDICAL CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAISY
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-720-2507
Mailing Address - Street 1:3705 GAGE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-1024
Mailing Address - Country:US
Mailing Address - Phone:310-720-2507
Mailing Address - Fax:310-219-0497
Practice Address - Street 1:3705 GAGE AVE STE A
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-1024
Practice Address - Country:US
Practice Address - Phone:310-720-2507
Practice Address - Fax:310-219-0497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA34603Medicaid