MEDICARE: PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	980000499	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164429684
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE HEALTH SYSTEM - SOUTHERN CALIFORNIA

Provider Business Mailing Address
First Line	:	250 E OLIVE AVE STE 202
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91502-1211
Country	:	US
Telephone Number	:	818-953-4451
Fax Number	:	747-229-2365

Provider Business Practice Location Address
First Line	:	250 E OLIVE AVE STE 202
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91502-1211
Country	:	US
Telephone Number	:	818-953-4451
Fax Number	:	747-229-2365

Authorized Official
Title or Position	:	ASSISTANT SECRETARY FOR ENROLLMENT
Name	:	DONALD W ANDERSON JR.
Credential	:
Telephone Number	:	425-358-9786

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	05/16/2025

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