1316989791 NPI number — LITTLE COMPANY OF MARY - SAN PEDRO

Table of content: (NPI 1316989791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316989791 NPI number — LITTLE COMPANY OF MARY - SAN PEDRO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LITTLE COMPANY OF MARY - SAN PEDRO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LITTLE COMPANY OF MARY PAVILION SAN - PEDRO
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316989791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6668
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN PEDRO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90734-6668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-303-7496
Provider Business Mailing Address Fax Number:
310-303-7575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 W 7TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN PEDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90732-3505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-303-7496
Provider Business Practice Location Address Fax Number:
310-303-7575
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ZUANICH
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
310-303-7496

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 056297 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZM1977B . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: LTX06297H , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZT06297H , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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