Basic Information
| Provider Information | |||||||||
| NPI: | 1104917426 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERCARE HEALTH SYSTEMS INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CITY OF ANGELS MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1711 WEST TEMPLE STREET | ||||||||
| Address2: | ATTN BUSINESS OFFICE | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900265421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139896100 | ||||||||
| FaxNumber: | 2134843552 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 WEST TEMPLE STREET | ||||||||
| Address2: | ATTN BUSINESS OFFICE | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900265421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2139896100 | ||||||||
| FaxNumber: | 2134843552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COWLES | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2139896114 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | CA | X | Hospitals | General Acute Care Hospital | 283Q00000X | CA | X | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSC30725F | 05 | CA | MEDICAID |