Basic Information
| Provider Information | |||||||||
| NPI: | 1922001809 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTA LOS ANGELES HOSPITALS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LOS ANGELES COMM HOSP, NORWALK COMM HOSP & LA COMM HOSP AT BELLFLOWER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4081 E OLYMPIC BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900233330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232670477 | ||||||||
| FaxNumber: | 3232610809 | ||||||||
| Practice Location | |||||||||
| Address1: | 4081 E OLYMPIC BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900233330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232670477 | ||||||||
| FaxNumber: | 3232610809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELDERS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | JON | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 7147881249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALTA HOSPITALS SYSTEM, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 930000039 | CA | N | Hospital Units | Psychiatric Unit | 314000000X | 930000039 | CA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 282N00000X | 930000039 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | ZZZD1917Z | 01 | CA | BLUE SHEILD | OTHER | HSP30663F | 05 | CA | MEDICAID | HSP40663F | 05 | CA | MEDICAID | HSC30663F | 05 | CA | MEDICAID | ZZZC8919Z | 01 | CA | BLUE SHIELD | OTHER | LTC70086F | 05 | CA | MEDICAID |