Provider Demographics
NPI:1750305116
Name:SAN PEDRO PENINSULA HOSPITAL
Entity Type:Organization
Organization Name:SAN PEDRO PENINSULA HOSPITAL
Other - Org Name:SAN PEDRO PENINSULA PAVILION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUANICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-303-7496
Mailing Address - Street 1:PO BOX 6668
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90734-6668
Mailing Address - Country:US
Mailing Address - Phone:310-303-7496
Mailing Address - Fax:310-303-7575
Practice Address - Street 1:1322 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3501
Practice Address - Country:US
Practice Address - Phone:310-303-7496
Practice Address - Fax:310-303-7575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTX06297GMedicaid
CA056297OtherBLUE CROSS PROV#
CAZZT06297GMedicaid
CAZZZM1977BOtherBLUE SHIELD PROV#
CA056297OtherBLUE CROSS PROV#