Provider Demographics
NPI:1669650792
Name:MEMORIA HOSPITAL OF GARDENA
Entity type:Organization
Organization Name:MEMORIA HOSPITAL OF GARDENA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:POPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-512-6204
Mailing Address - Street 1:1145 W REDONDO BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-3528
Mailing Address - Country:US
Mailing Address - Phone:310-512-6169
Mailing Address - Fax:310-512-6126
Practice Address - Street 1:1145 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3528
Practice Address - Country:US
Practice Address - Phone:310-512-6169
Practice Address - Fax:310-512-6126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHB463690Medicaid