Provider Demographics
NPI:1609901016
Name:PROVIDENCE SAINT JOHN'S HEALTH CENTER
Entity Type:Organization
Organization Name:PROVIDENCE SAINT JOHN'S HEALTH CENTER
Other - Org Name:PROVIDENCE SAINT JOHNS HEALTH COP
Other - Org Type:Other Name
Authorized Official - Title/Position:OUTPATIENT DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:CANAS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:310-829-8921
Mailing Address - Street 1:1339 20TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2033
Mailing Address - Country:US
Mailing Address - Phone:310-829-8921
Mailing Address - Fax:310-829-8455
Practice Address - Street 1:1339 20TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2033
Practice Address - Country:US
Practice Address - Phone:310-829-8921
Practice Address - Fax:310-829-8455
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROVIDENCE SAINT JOHN'S HOSPITAL AND HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-23
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA569538251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000006773Medicaid