1962069393 NPI number — ST JOHN COMMUNITY HEALTH CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962069393 NPI number — ST JOHN COMMUNITY HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST JOHN COMMUNITY HEALTH CENTER
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:
Provider Other Organization Name Type Code:
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:
1962069393
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2112 S GAREY AVE STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91766-5600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-464-0520
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2112 S GAREY AVE STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POMONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91766-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-464-0520
Provider Business Practice Location Address Fax Number:
909-464-0523
Provider Enumeration Date:
05/21/2019

Additional Information

Authorized Official

Authorized Official Last Name:
FRANCO
Authorized Official First Name:
VALERIE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
909-464-0520

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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