Basic Information
| Provider Information | |||||||||
| NPI: | 1073665360 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ST. JOHN'S REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2415 ANTONIO AVE | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930101459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053895800 | ||||||||
| FaxNumber: | 8053837460 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 N ROSE AVE | ||||||||
| Address2: | |||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930303722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059882701 | ||||||||
| FaxNumber: | 8059814440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 09/12/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WARDWELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8053895113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 050000064 | CA | N | Hospital Units | Rehabilitation Unit | 261QA1903X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 282N00000X | 050000064 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 050082B000000 | 01 | TRAILBLAZERS | OTHER | ZZT30082G | 05 | CA | MEDICAID | 62660 | 01 | AENTA | OTHER | HSC30082G | 05 | CA | MEDICAID | ZZZC5602Z | 01 | BLUE SHIELD | OTHER | 651191373E | 01 | HEALTHNET | OTHER | 651191373930300002 | 01 | WPS TRICARE | OTHER | 651191373 | 01 | IRS | OTHER | 651191373930300000 | 01 | WPS | OTHER | ZZT40082G | 05 | CA | MEDICAID |