Healthcare Provider Details

I. General information

NPI: 1679609648
Provider Name (Legal Business Name): PROVIDENCE SAINT JOHN'S HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1339 20TH ST
SANTA MONICA CA
90404-2033
US

IV. Provider business mailing address

1339 20TH ST
SANTA MONICA CA
90404-2033
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-8921
  • Fax: 310-829-8455
Mailing address:
  • Phone: 310-829-8921
  • Fax: 310-829-8455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number569538
License Number StateCA

VIII. Authorized Official

Name: MRS. RUTH CANAS
Title or Position: OUTPATIENT DIRECTOR
Credential: LCSW
Phone: 310-829-8921