Basic Information
| Provider Information | |||||||||
| NPI: | 1770659336 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIGNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ARROYO GRANDE COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 722 E MAIN ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934544595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056145522 | ||||||||
| FaxNumber: | 8056145985 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 S HALCYON RD | ||||||||
| Address2: | |||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934203896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054894261 | ||||||||
| FaxNumber: | 8054737603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2006 | ||||||||
| LastUpdateDate: | 09/13/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSEN | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8057393600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIGNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 050000021 | CA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 273Y00000X | N | Hospital Units | Rehabilitation Unit | 282N00000X | 050000021 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | ZZT40016J | 05 | CA | MEDICAID | 510509286 | 01 | CA | COMMERCIAL INS | OTHER | HSC30016J | 05 | CA | MEDICAID | 510509286941390000 | 01 | CA | TRIWEST | OTHER | ZZZC4001Z | 01 | CA | BLUE SHIELD | OTHER | 050016B000000 | 01 | CA | TRAILBLAZER | OTHER |