Basic Information
Provider Information | |||||||||
NPI: | 1114021250 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JUPITER BELLFLOWER DOCTORS HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BELLFLOWER MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9542 EAST ARTESIA BLVD | ||||||||
Address2: |   | ||||||||
City: | BELLFLOWER | ||||||||
State: | CA | ||||||||
PostalCode: | 90706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5629258355 | ||||||||
FaxNumber: | 9497324671 | ||||||||
Practice Location | |||||||||
Address1: | 9542 EAST ARTESIA BLVD | ||||||||
Address2: |   | ||||||||
City: | BELLFLOWER | ||||||||
State: | CA | ||||||||
PostalCode: | 90706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5629258355 | ||||||||
FaxNumber: | 9497324671 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/11/2006 | ||||||||
LastUpdateDate: | 08/12/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLOM | ||||||||
AuthorizedOfficialFirstName: | CLARA | ||||||||
AuthorizedOfficialMiddleName: | RUTH | ||||||||
AuthorizedOfficialTitleorPosition: | VP/HOSPITAL CFO | ||||||||
AuthorizedOfficialTelephone: | 3104638273 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 00899 | CA | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | HSP40531H | 05 | CA |   | MEDICAID | HSC30531H | 05 | CA |   | MEDICAID | HSM30531H | 05 | CA |   | MEDICAID |