Provider Demographics
NPI:1336438902
Name:SAINT JOHN'S HEALTH CLINIC
Entity Type:Organization
Organization Name:SAINT JOHN'S HEALTH CLINIC
Other - Org Name:PROVIDENCE SAINT JOHN'S HEALTH CLINIC
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:W
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:PO BOX 31001-3029
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-3029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:310-829-8754
Practice Address - Fax:310-829-8062
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT JOHN'S HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-04
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74690174400000X
CAG31595174400000X
CAG34311174400000X
CAA102707174400000X
CAG27424174400000X
CAA108734174400000X
CAA81646174400000X
CAA76881174400000X
CAG70184174400000X
CAA76707174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty