Basic Information
| Provider Information | |||||||||
| NPI: | 1417089350 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY COMMUNITY CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | NORTHRIDGE HOSPITAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3215 PROSPECT PARK DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956706017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884887667 | ||||||||
| FaxNumber: | 9164144741 | ||||||||
| Practice Location | |||||||||
| Address1: | 18300 ROSCOE BLVD | ||||||||
| Address2: | |||||||||
| City: | NORTHRIDGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913254105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188858500 | ||||||||
| FaxNumber: | 8188855439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8188855321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY COMMUNITY CARE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 930000114 | CA | N | Hospital Units | Psychiatric Unit | 273Y00000X | 930000114 | CA | N | Hospital Units | Rehabilitation Unit | 282N00000X | 930000114 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | NHRC | 01 | CA | UNIVERSAL | OTHER | 2720268 | 01 | CA | AETNA | OTHER | 870692258 | 01 | CA | IRS | OTHER | HSC30116F | 05 | CA | MEDICAID | ZZT40116G | 05 | CA | MEDICAID | ZZZA1957Z | 01 | CA | BLUE SHIELD | OTHER | 050116B0000 | 01 | CA | CMS SECTION 1011 | OTHER | CGP00685 | 01 | CA | DHS | OTHER | HSM30116G | 05 | CA | MEDICAID | ZZT30116G | 05 | CA | MEDICAID | 870692258913250000 | 01 | CA | WPS TRICARE | OTHER | CGP010485 | 01 | CA | DHS | OTHER | HSC30116G | 05 | CA | MEDICAID | HSM30116F | 05 | CA | MEDICAID | ZZT30116F | 05 | CA | MEDICAID | ZZT40116F | 05 | CA | MEDICAID |