Healthcare Provider Details

I. General information

NPI: 1770639809
Provider Name (Legal Business Name): PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 W 6TH ST
SAN PEDRO CA
90732-3501
US

IV. Provider business mailing address

PO BOX 31001-3017
PASADENA CA
91110-3017
US

V. Phone/Fax

Practice location:
  • Phone: 310-303-7496
  • Fax: 310-303-7575
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

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