Healthcare Provider Details

I. General information

NPI: 1689875601
Provider Name (Legal Business Name): PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15031 RINALDI STREET
MISSION HILLS CA
91345-1207
US

IV. Provider business mailing address

15031 RINALDI STREET
MISSION HILLS CA
91345-1207
US

V. Phone/Fax

Practice location:
  • Phone: 818-365-8051
  • Fax: 818-898-4569
Mailing address:
  • Phone: 818-365-8051
  • Fax: 818-898-4569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DONALD W ANDERSON JR.
Title or Position: ASSISTANT SECRETARY ENROLLMENTS
Credential:
Phone: 425-358-9786