Basic Information
| Provider Information | |||||||||
| NPI: | 1639101116 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SIERRA VISTA HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SIERRA VISTA REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE 57445 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900747445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095782513 | ||||||||
| FaxNumber: | 8055467892 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 MURRAY ST | ||||||||
| Address2: | |||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934058800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055467600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WARTELLE | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8055467797 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 050000059 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 050506B000000 | 01 | SECTION 1011 | OTHER | 978127350 | 01 | AETNA US HEALTHCARE | OTHER | ZZT40506F | 05 | CA | MEDICAID | HSC30506F | 05 | CA | MEDICAID | 005873-0001 | 01 | PACIFICARE OF CALIFORNIA | OTHER | 000436 | 01 | HUMANA | OTHER | 050506 | 01 | BC OF CALIFORNIA | OTHER | ZZZA4002Z | 01 | BS OF CALIFORNIA | OTHER |