1194735886 NPI number — LODI MEMORIAL HOSPITAL ASSOCIATION INC

Table of content: (NPI 1194735886)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194735886 NPI number — LODI MEMORIAL HOSPITAL ASSOCIATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LODI MEMORIAL HOSPITAL ASSOCIATION INC
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:
LODI MEMORIAL URGENT CARE CLINIC
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:
1194735886
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3004
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LODI
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95241-1908
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-334-3411
Provider Business Mailing Address Fax Number:
209-339-7659

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1235 W VINE ST STE 20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LODI
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95240-5109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-339-7625
Provider Business Practice Location Address Fax Number:
209-339-7659
Provider Enumeration Date:
08/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARRINGTON
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
P
Authorized Official Title or Position:
CEO CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
209-334-3411

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  030000056 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X , with the licence number: 030000056 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0086833 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ53356Z . This is a "BLUE SHIELD PROV GRP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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