1144497678 NPI number — DIGNITY HEALTH MEDICAL FOUNDATION

Table of content: (NPI 1144497678)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144497678 NPI number — DIGNITY HEALTH MEDICAL FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIGNITY HEALTH MEDICAL FOUNDATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WOODLAND CLINIC, A SERVICE OF DIGNITY HEALTH MEDICAL FOUNDATION
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144497678
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 748217
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-8217
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-666-1631
Provider Business Mailing Address Fax Number:
530-666-7255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
632 W GIBSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95695-5169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-666-1631
Provider Business Practice Location Address Fax Number:
530-666-7255
Provider Enumeration Date:
05/14/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LENZI
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
916-851-2559

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 571205856 . This is a "IRS - SP TIN" identifier . This identifiers is of the category "OTHER".