Provider Demographics
NPI:1902844988
Name:PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM SOUTHERN CALIFORNIA
Other - Org Name:PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 31001-3017
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-3017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4101 TORRANCE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4607
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:2006-06-03
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT403053GMedicaid
CAHSC30353GMedicaid
CAZZZA1934ZOtherBLUE SHIELD PROVIDER NUMB
CAZZT30353GMedicaid
CA050353OtherBLUE CROSS PROVIDER NUMBE
CAZZT30353GMedicaid
CAZZT403053GMedicaid
CAZZZA1934ZOtherBLUE SHIELD PROVIDER NUMB
CAW19281Medicare ID - Type UnspecifiedMEDICARE PROVIDER # PROF