Healthcare Provider Details

I. General information

NPI: 1124026273
Provider Name (Legal Business Name): PROVIDENCE SAINT JOHN'S HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 SANTA MONICA BLVD
SANTA MONICA CA
90404-2303
US

IV. Provider business mailing address

1328 22ND ST
SANTA MONICA CA
90404-2032
US

V. Phone/Fax

Practice location:
  • Phone: 310-829-5511
  • Fax: 310-315-6135
Mailing address:
  • Phone: 310-829-5511
  • Fax: 310-315-6135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number930000158
License Number StateCA

VIII. Authorized Official

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