Provider Demographics
NPI:1598961245
Name:DIGNITY HEALTH MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:DIGNITY HEALTH MEDICAL FOUNDATION
Other - Org Name:DIGNITY HEALTH MEDICAL GROUP - DOMINICAN, A SERVICE OF DIGNITY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HYLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-851-2559
Mailing Address - Street 1:PO BOX 742513
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-2513
Mailing Address - Country:US
Mailing Address - Phone:916-733-5701
Mailing Address - Fax:916-733-3401
Practice Address - Street 1:1595 SOQUEL DR STE 400
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1724
Practice Address - Country:US
Practice Address - Phone:831-475-1111
Practice Address - Fax:831-476-5020
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIGNITY HEALTH MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-21
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0091684Medicaid
ZZZ50291ZOtherBSCA
ZZZ50291ZOtherBSCA