Provider Demographics
NPI:1588822068
Name:DIGNITY HEALTH
Entity Type:Organization
Organization Name:DIGNITY HEALTH
Other - Org Name:ST. JOHN'S HOSPITAL OUTPATIENT LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WARDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-225-6121
Mailing Address - Street 1:2415 ANTONIO AVE
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-1459
Mailing Address - Country:US
Mailing Address - Phone:805-988-7090
Mailing Address - Fax:805-981-7399
Practice Address - Street 1:1600 N ROSE AVE
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3722
Practice Address - Country:US
Practice Address - Phone:805-988-7090
Practice Address - Fax:805-981-7399
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIGNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-30
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 1206291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT40082GMedicaid
ZZZC5602ZOtherBSCA
62660OtherAETNA
651191373930300000OtherWPS/TRICARE - GENERAL ACUTE
651191373EOtherHEALTH NET
651191373930300002OtherWPS/TRICARE - REHAB
ZZZC5602ZOtherBSCA
CA050082Medicare Oscar/Certification