Basic Information
| Provider Information | |||||||||
| NPI: | 1194735886 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LODI MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LODI MEMORIAL URGENT CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3004 | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952411908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093343411 | ||||||||
| FaxNumber: | 2093397659 | ||||||||
| Practice Location | |||||||||
| Address1: | 1235 W VINE ST STE 20 | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952405109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093397625 | ||||||||
| FaxNumber: | 2093397659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 12/21/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRINGTON | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2093343411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LODI MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 030000056 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | 261QU0200X | 030000056 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | GR0086833 | 05 | CA | MEDICAID | ZZZ53356Z | 01 | CA | BLUE SHIELD PROV GRP | OTHER |