Basic Information
| Provider Information | |||||||||
| NPI: | 1245371343 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLYMPIA HEALTH CARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OLYMPIA MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5900 W OLYMPIC BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900364671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106575900 | ||||||||
| FaxNumber: | 3239325163 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 W OLYMPIC BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900364671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106575900 | ||||||||
| FaxNumber: | 3239325163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 04/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3239325062 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 93000105 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP30477H | 05 | CA | MEDICAID | HSP40477H | 05 | CA | MEDICAID |