Basic Information
| Provider Information | |||||||||
| NPI: | 1316938301 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LODI MEMORIAL HOSPITAL ASSOCIATION INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LODI MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 975 S FAIRMONT AVE | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952405118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093343411 | ||||||||
| FaxNumber: | 2093397659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITNEY | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2093397477 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 030000056 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP40336F | 01 | CA | CHDP | OTHER | HSP40336F | 05 | CA | MEDICAID | HSC00336F | 05 | CA | MEDICAID | ZZR00336F | 01 | CA | CMSP DEPT OF HEALTH SVC | OTHER | ZZZC3903Z | 01 | CA | BLUE SHIELD IN & OUTPT | OTHER |