Provider Demographics
NPI:1891718797
Name:SAN PEDRO PENINSULA HOSPITAL
Entity Type:Organization
Organization Name:SAN PEDRO PENINSULA HOSPITAL
Other - Org Name:LITTLE COMPANY OF MARY SUB ACUTE CARE CENTER
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:310-303-7561
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:310-303-7561
Mailing Address - Fax:310-303-7575
Practice Address - Street 1:3620 LOMITA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3938
Practice Address - Country:US
Practice Address - Phone:310-303-7561
Practice Address - Fax:310-303-7575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
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
CAZZT18678JMedicaid
CA056490OtherBLUE CROSS PROV#
CAZZZM1978BOtherBLUE SHIELD PROV#
CA056490OtherBLUE CROSS PROV#
CALTC70027GMedicare ID - Type UnspecifiedMEDI-CAL VENT PRV# OLD