Provider Demographics
NPI:1780843805
Name:DIGNITY HEALTH
Entity Type:Organization
Organization Name:DIGNITY HEALTH
Other - Org Name:ST. JOHN'S PLEASANT VALLEY 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:805-389-5113
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:805-389-5115
Mailing Address - Fax:805-383-7461
Practice Address - Street 1:2309 ANTONIO AVE
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-1414
Practice Address - Country:US
Practice Address - Phone:805-389-5880
Practice Address - Fax:805-389-5883
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIGNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-04
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF 2581291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZA5606ZOtherBSCA
870692236930100002OtherWPS/TRICARE - SNF
51406OtherAETNA
870692236930100000OtherWPS/TRICARE - GENERAL ACUTE
CAHSP40616IMedicaid
870692236BOtherHEALTH NET
CAHSP40616IMedicaid
870692236930100002OtherWPS/TRICARE - SNF