Provider Demographics
NPI:1568422319
Name:ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC
Entity Type:Organization
Organization Name:ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC
Other - Org Name:PROVIDENCE HUMBOLDT HOME INFUSION
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:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:2612 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3223
Mailing Address - Country:US
Mailing Address - Phone:707-269-4258
Mailing Address - Fax:707-269-3755
Practice Address - Street 1:2612 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501
Practice Address - Country:US
Practice Address - Phone:707-269-4258
Practice Address - Fax:707-269-3755
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOSEPH HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-24
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CAPHY456193336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1997874OtherPK
CAPHA456190Medicaid
1151710001Medicare NSC