Healthcare Provider Details

I. General information

NPI: 1609358977
Provider Name (Legal Business Name): PROVIDENCE MEDICAL INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 TORRANCE BLVD
TORRANCE CA
90503-4607
US

IV. Provider business mailing address

21311 MADRONA AVE STE 101
TORRANCE CA
90503-5970
US

V. Phone/Fax

Practice location:
  • Phone: 310-303-6833
  • Fax:
Mailing address:
  • Phone: 310-792-4015
  • Fax: 310-792-4093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MR. DONALD WAYNE ANDERSON
Title or Position: ASSISTANT SECRETARY-ENROLLMENT
Credential:
Phone: 425-525-5392