Provider Demographics
NPI:1801256789
Name:GROSSMONT HOSPITAL CORPORATION
Entity type:Organization
Organization Name:GROSSMONT HOSPITAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-740-4648
Mailing Address - Street 1:5555 GROSSMONT CENTER DR
Mailing Address - Street 2:A217
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3019
Mailing Address - Country:US
Mailing Address - Phone:619-740-4458
Mailing Address - Fax:619-740-4266
Practice Address - Street 1:5555 GROSSMONT CENTER DR # A217
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-740-4458
Practice Address - Fax:619-740-4266
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GROSSMONT HOSPITAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-04
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CA536753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158472OtherPK