Healthcare Provider Details

I. General information

NPI: 1811907512
Provider Name (Legal Business Name): LODI MEMORIAL HOSPITAL ASSOCIATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 W VINE ST SUITE 103
LODI CA
95242-3731
US

IV. Provider business mailing address

PO BOX 884577
LOS ANGELES CA
90088-4577
US

V. Phone/Fax

Practice location:
  • Phone: 209-333-3030
  • Fax: 209-339-7659
Mailing address:
  • Phone: 209-334-3411
  • Fax: 209-339-7659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number030000056
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: JASON WHITNEY
Title or Position: FINANCE OFFICER
Credential:
Phone: 209-339-7477