Provider Demographics
NPI:1245454982
Name:KAISER PERMANENTE, SUNSET BL. LA, ,CA
Entity type:Organization
Organization Name:KAISER PERMANENTE, SUNSET BL. LA, ,CA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY-JEANNE
Authorized Official - Middle Name:H
Authorized Official - Last Name:DER AVEDISSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS,RD
Authorized Official - Phone:323-783-1552
Mailing Address - Street 1:626 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1612
Mailing Address - Country:US
Mailing Address - Phone:818-240-4328
Mailing Address - Fax:
Practice Address - Street 1:4867 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-5969
Practice Address - Country:US
Practice Address - Phone:323-783-1552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA590756282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1245454982OtherHOSPITAL