Basic Information
| Provider Information | |||||||||
| NPI: | 1558608554 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTY OF LOS ANGELES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAC HARBOR UCLA MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 W CARSON ST | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905022004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4243066580 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 W CARSON ST | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905022004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4243066580 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2013 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BANUELOS | ||||||||
| AuthorizedOfficialFirstName: | ROSITA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4243067501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF LOS ANGELES | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 60000129 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HAP40376F | 05 | CA | MEDICAID |