MEDICARE: DIGNITY HEALTH MEDICAL FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7291	OTHER		STOCKTON LOC - HEALTHNET
3	371518341	OTHER		STOCKTON LOC - IRS SP TAX
4	ZZZ66457Z	OTHER	CA	BLUE SHIELD

General Provider Information

NPI Number	:	1861410581
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIGNITY HEALTH MEDICAL FOUNDATION

Provider Business Mailing Address
First Line	:	PO BOX 742027
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90074-2027
Country	:	US
Telephone Number	:	916-379-2840
Fax Number	:	916-859-1106

Provider Business Practice Location Address
First Line	:	3132 W MARCH LN
Second Line	:	SUITE 5
City	:	STOCKTON
State	:	CA
Zip	:	95219-2354
Country	:	US
Telephone Number	:	209-475-5500
Fax Number	:	209-475-5515

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	THERESA M HYLEN
Credential	:
Telephone Number	:	916-851-2559

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	11/18/2020

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Directions to “DIGNITY HEALTH MEDICAL FOUNDATION ” Practice Location

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