=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194083824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROVIDENCE FACEY MEDICAL FOUNDATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2012
-----------------------------------------------------
Last Update Date | 05/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11333 SEPULVEDA BLVD SUITE 3200
-----------------------------------------------------
City | MISSION HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91345-1116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-837-5776
-----------------------------------------------------
Fax | 818-837-5810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | FILE 50670
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90074-0670
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT SECRETARY OF ENROLLMENTS
-----------------------------------------------------
Name | DONALD WAYNE ANDERSON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-358-9786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------