Basic Information
| Provider Information | |||||||||
| NPI: | 1043257041 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LODI MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LODI MEMORIAL HOSPITAL HOME HEALTH AGENCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3004 | ||||||||
| Address2: | 975 S FAIRMONT AVE | ||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952411908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093343411 | ||||||||
| FaxNumber: | 2093397659 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 S LOWER SACRAMENTO RD | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952423635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093343411 | ||||||||
| FaxNumber: | 2093397659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 12/21/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRINGTON | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2093343411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LODI MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 100000269 | CA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | HHA70079F | 05 | CA | MEDICAID |