Basic Information
| Provider Information | |||||||||
| NPI: | 1568646735 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY COMMUNITY CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SEQUOIA HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3215 PROSPECT PARK DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956706017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168611102 | ||||||||
| FaxNumber: | 9168617707 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 ALAMEDA DE LAS PULGAS | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940622751 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503695811 | ||||||||
| FaxNumber: | 6503675100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2007 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OSBORNE | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6503675837 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY COMMUNITY CARE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 220000045 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | LAB00197F | 05 | CA | MEDICAID | ZZR00197G | 05 | CA | MEDICAID | HSP40197G | 05 | CA | MEDICAID | HSC00197G | 05 | CA | MEDICAID | ZZZA4102Z | 01 | BLUE SHIELD CA | OTHER | 02 | 01 | KAISER | OTHER |