Basic Information
Provider Information | |||||||||
NPI: | 1134325889 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DIGNITY HEALTH MEDICAL FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DIGNITY HEALTH MEDICAL GROUP - DOMINICAN, A SERVICE OF DIGNITY HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3000 Q ST | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958167058 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9167335701 | ||||||||
FaxNumber: | 9167333401 | ||||||||
Practice Location | |||||||||
Address1: | 1595 SOQUEL DR | ||||||||
Address2: | SUITE 411 | ||||||||
City: | SANTA CRUZ | ||||||||
State: | CA | ||||||||
PostalCode: | 950651719 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8314657778 | ||||||||
FaxNumber: | 8314750351 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/21/2007 | ||||||||
LastUpdateDate: | 11/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HYLEN | ||||||||
AuthorizedOfficialFirstName: | THERESA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9168512559 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DIGNITY HEALTH MEDICAL FOUNDATION | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | GR0091682 | 05 | CA |   | MEDICAID | ZZZ50289Z | 01 |   | BSCA | OTHER |