Basic Information
| Provider Information | |||||||||
| NPI: | 1023010113 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN CALIFORNIA HEALTHCARE SYSTEM, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD, AT VAN NUYS, AT CULVER CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3415 S SEPULVEDA BLVD FL 9 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900346060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3109434500 | ||||||||
| FaxNumber: | 3109434501 | ||||||||
| Practice Location | |||||||||
| Address1: | 6245 DE LONGPRE AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900288253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234622271 | ||||||||
| FaxNumber: | 3234633830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2005 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | ZILKOW | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3109434500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALTA HOSPITALS SYSTEM, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 930000066 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP30135I | 05 | CA | MEDICAID | ZZZC9928Z | 01 | CA | BLUE SHEILD | OTHER | HSP40135I | 05 | CA | MEDICAID | HSC30135I | 05 | CA | MEDICAID |