Basic Information
| Provider Information | |||||||||
| NPI: | 1194083824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROVIDENCE FACEY MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FACEY ENDOSCOPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9602 | ||||||||
| Address2: | |||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913469602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188375691 | ||||||||
| FaxNumber: | 8187924793 | ||||||||
| Practice Location | |||||||||
| Address1: | 11333 SEPULVEDA BLVD | ||||||||
| Address2: | SUITE 3200 | ||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913451116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188375776 | ||||||||
| FaxNumber: | 8188375810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2012 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY FOR ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4255255392 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FACEY MEDICAL FOUNDATION | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.