Basic Information
| Provider Information | |||||||||
| NPI: | 1992876767 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY MEMORIAL HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OJAI VALLEY COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 147 N BRENT ST | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930032809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056525011 | ||||||||
| FaxNumber: | 8055853007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1306 MARICOPA HWY | ||||||||
| Address2: | |||||||||
| City: | OJAI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930233131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056461401 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILDE | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 8056525001 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY MEMORIAL HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | N | Hospital Units | Medicare Defined Swing Bed Unit | 282NC0060X | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 050394 | 01 | CA | BLUE CROSS PROVIDER NO | OTHER | ZZZA5609Z | 01 | CA | BLUE SHIELD PROVIDER NO | OTHER | HSP40046L | 05 | CA | MEDICAID | ZZZ53994Z | 01 | CA | BLUE SHIELD | OTHER | ZZZA5603Z | 01 | CA | BLUE SHIELD | OTHER | 05Z334 | 01 | CA | MEDICARE OSCAR SWING BED | OTHER | HSC30046L | 05 | CA | MEDICAID |