Basic Information
| Provider Information | |||||||||
| NPI: | 1174531859 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY HEALTH MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIGNITY HEALTH MEDICAL GROUP - SEQUOIA, A SERVICE OF DIGNITY HEALTH ME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742852 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900742852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163792840 | ||||||||
| FaxNumber: | 9168591106 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 SHOREWAY RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BELMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940024151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505967000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HYLEN | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9168512559 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY HEALTH MEDICAL FOUNDATION | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 113737342 | 01 | IRS - SP TAX ID | OTHER | 4601 | 01 | HEALTHNET | OTHER | ZZZ66458Z | 01 | CA | BLUE SHIELD | OTHER |