Basic Information
| Provider Information | |||||||||
| NPI: | 1477610640 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY COMMUNITY CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1420 S CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912042508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185021900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1420 S CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912042508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185022215 | ||||||||
| FaxNumber: | 8184097688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GUOYAVATIN | ||||||||
| AuthorizedOfficialFirstName: | KORA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8185022204 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY COMMUNITY CARE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 930000099 | CA | N | Hospital Units | Psychiatric Unit | 273Y00000X | 930000099 | CA | N | Hospital Units | Rehabilitation Unit | 314000000X | 930000099 | CA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 282N00000X | 930000099 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 774509 | 01 | CA | AETNA | OTHER | GMH | 01 | CA | UNIVERSAL | OTHER | ZZT30058G | 05 | CA | MEDICAID | HSM30058G | 05 | CA | MEDICAID | 050058B000000 | 01 | CA | CMS SECTION 1011 | OTHER | CGP164950 | 01 | CA | DHS | OTHER | HSC30058G | 05 | CA | MEDICAID | ZZZA1903Z | 01 | CA | BLUE SHIELD | OTHER | 951642380 | 01 | CA | IRS | OTHER | 951642380912040003 | 01 | CA | WPS TRICARE | OTHER | ZZT40058G | 05 | CA | MEDICAID |