Basic Information
| Provider Information | |||||||||
| NPI: | 1194877332 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ST. JOHN'S PLEASANT VALLEY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2415 ANTONIO AVE | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930101459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053895800 | ||||||||
| FaxNumber: | 8053837460 | ||||||||
| Practice Location | |||||||||
| Address1: | 2309 ANTONIO AVE | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930101414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053895632 | ||||||||
| FaxNumber: | 8053837450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 09/13/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAURICE | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8059882500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 050000048 | CA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 282N00000X | 050000048 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP30616I | 05 | CA | MEDICAID | 51406 | 01 | AETNA | OTHER | HSC30616I | 05 | CA | MEDICAID | HSP40616I | 05 | CA | MEDICAID | ZZZA5606Z | 01 | BLUE SHIELD | OTHER | 870692236930100000 | 01 | WPS | OTHER | LTC70024G | 05 | CA | MEDICAID | 870692236 | 01 | IRS | OTHER | 870692236930100002 | 01 | WPS | OTHER | 870692236B | 01 | HEALTHNET | OTHER | LTC55223G | 05 | CA | MEDICAID |