Basic Information
| Provider Information | |||||||||
| NPI: | 1306855523 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LODI MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LODI MEMORIAL PRIMARY CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 884577 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900884577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093343411 | ||||||||
| FaxNumber: | 2093397659 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 W VINE ST STE 105 | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952423731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093333121 | ||||||||
| FaxNumber: | 2093397659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITNEY | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2093397477 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LODI MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 030000056 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | ZZZ53358Z | 01 | CA | BLUE SHIELD PROV GRP | OTHER | GR0086832 | 05 | CA | MEDICAID |